COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX00034550 


ffifllumbia  Mmu^mtg        ^ 
in  t\^t  Olitg  0f  Nfui  f  nrk 


Hfffrfttrp   Slibrarg 


z 


CLINICAL   MANUALS 

FOU 

Practitioners  and  Students 
OF  Medicine. 


Intestinal  Obstruction: 


ITS    YAEIETIES. 


WITH 


THEIK  PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT. 

The  Jaclisonian  Prize  Essay  of  the  Royal  College 
of  Surgeons  of  England,  1883. 


BY 

FREBEEICK  TREVES,  F.R.C.S., 

SURGEON     TO     AND    LECTURER    ON     ANATOMY    AT   THE    LONDON   HOSPITAL; 

HUNTERIAN    PROFESSOR     OF    ANATOMY    AT    THE     ROYAL 

COLLEGE   OF   SURGEONS   OF   ENGLAND. 


WITH    60    ILLUSTRATIONS. 


FHILABELPEIA  : 
HENPtY    C.    LEA'S    SON    &    00. 

1884. 


JOHN   STRTJTHERS,   Esq.,   M.D., 

PROFESSOR  OF  ANATOMY  AT  THE   UNIVERSITY    OF    ABERDEEN, 

AS   A    TOKEN    OF    RESPECT 

FOR   HIS   POSITION    AS    .^'   ANATOMIST, 

AND    AS    A 

SLIGHT   ACKNOWLEDGMENT    OF   JIANY    ACTS    OF   KINDNESS. 


PEEFACE. 


The  importance  of  the  subject  of  Intestinal  Obstruc- 
tion may  be,  in  one  way,  estimated  by  the  circum- 
stance that  over  two  thousand  individuals  die  every 
year  in  England  alone  from  various  forms  of  obstruc- 
tion of  the  bowels,  exclusive  of  hernia. 

In  the  foUowino-  work  I  have  based  the  classifica- 
tion  of  the  different  varieties  of  Intestinal  Obstruction 
upon  pathological  grounds  rather  than  upon  clinical 
distinctions.  Tliis  has  been  done  for  two  reasons. 
In  the  hrst  place,  the  knowledge  of  the  morbid 
anatomy  of  Intestinal  Obstruction  is  much  more 
extensive  and  precise  than  is  the  knowledge  of  its 
clinical  history;  and,  secondly,  the  arrangement  is 
more  convenient,  inasmuch  as  it  avoids  much  repe- 
tition which  would  otherwise  be  necessary.  A  classi- 
fication, however,  based  upon  purely  clinical  grounds 
is  extremely  desirable,  and  this  classification  I  have 
attempted  in  the  chapters  upon  diagnosis. 

In  the  consideration  of  the  A^arious  forms  of  the 
present  afi'ection  I  have  dealt  first  with  the  patho- 
logical aspect  of  the  case,  then  with  the  symptoms, 
and  finally  with  the  prognosis.  The  general  diagnosis 
of  Intestinal  Obstruction,  as  a  whole,  is  reserved  for 
some    special    chapters,    and    the    same    method   has 


viii  Intestinal  Obstruction, 

been  adopted  with  regard  to  the  whole  subject  of 
treatment. 

The  drawings  are,  with  a  very  few  exceptions, 
original,  and  I  am  indebted  to  the  artist,  Mr.  R.  E. 
Holding,  for  the  care  he  has  expended  upon  them. 

The  work  is  in  substance  the  Essay  to  which  the 
Jacksonian  Prize  was  awarded  by  the  College  of 
Surgeons  in  1884.  The  Essay  was  completed  in 
December,  1883.  It  has  been  entirely  revised,  some 
parts  have  been  re-Avritten,  and  such  new  matter  lias 
been  introduced  as  was  required  to  bring  the  work  up 
to  date. 

My  thanks  are  due  to  the  Council  of  the  College 
of  Surgeons  for  permission  to  publish  the  Essay  and 
certain  of  the  plates  that  illustrate  it. 

FREDERICK   TREVES. 

18,  Gordon  Square,  W.C. 

iSejjtember,  1884. 


CONTENTS. 


CHAPTER  PAGE 

I.— The  Classification  of  Intestinal  Obstkuction      1 

n.— Some  Especial  Features  in  the  Etiology  of 

Intestinal  Obstruction S 

ni.— Strangulation  by  Bands  or  through  Aper- 
tures—Hernia-like  Strangulation  of  the 
Bowel IS 

rv.— Strangulation  by  Bands  or  throlgh  Aper- 
tures—Symptoms     62 

v.— Strangulation  by  Bands   or  through  Apek- 

TURES— Course  and  Prognosis  ....     91 

VI.— Anomalous    Forms    of    Obstruction    due    to 

Isolated  Bands  and  to  Adhesions  ...     96 

YII.— Volvulus 134 

Vni.— Intussusception— Pathology 166 

IX.— The  Etiology  of  Intussusception  .       .       .       .202 

X.— The  Symptoms  op  Intussusception        .       .       .215 

XI.— The  Course  and  Prognosis  of  Intussusception    212 

Xn.— Stricture  of  the  Intestine— Pathology    .       .    252 

Xm.— The  Symptoms  and  Prognosis  of  Stricture  of 

THE  Intestine 285 

XIV.— Obstruction  of  the  Intestine  by  Neoplasms  .    309 

XV.— Compression  of  the  Intestine  by  Tumours,  etc., 

external  to  the  Bowel 315 

XVI.— Obstruction    of    the    Intestine    by    Foreign 

Bodies 319 


■X  Intestinal  Obstruction. 

CHAPTEK,  PAGE 

XVn.— Obstruction  op  the  Intestine  by  Gall  Stones    323 

XVIII.— Obstruction  by  Intestinal  Stones        .       .       .    33G 

XIX.— Obstruction  of  the  Intestine  by  F^cal  Masses 

—Chronic  Constipation— Ileus  Paralyticus    3U 

XX.— The   Diagnosis— The  General  Significance  of 

the  Leading  Symptoms 355 

XXI.— The  Diagnosis    of  the    different  Forms  of 

Intestinal  Obstruction 371 

XXII.— The  Symptoms  as  modified  by  the  Position  of 

THE  Obstruction 391 

XXIII— The  various  Affections  that  have  been  most 

FREQUENTLY    CONFUSED    WITH    CaSES    OF    OB- 
STRUCTION OF  THE  Bowels 100 

XXIV.— The  Treatment— Non-Operative  Measures       .    115 

XXV.— The  Treatment— Operative  Measures        .       .    415 

XXVI.— The  Special  Treatment  of  Individual  Forms 

of  Obstruction 193 

Index      .  509 


toTESTiNAL  Obstruction. 


CHAPTER   I. 

THE    CLASSIFICATION    OF    INTESTINAL    OBSTRUCTION. 

There  are  several  cliiFerent  plans  upon  wliicli  a 
classification  of  the  various  forms  of  intestinal  ob- 
struction niaj  be  based. 

Bj  one  method  they  may  be  divided  into  the  two 
great  classes  of  the  congenital  and  the  acquired, 
according  to  whether  the  conditions  that  produced 
the  obstruction  existed  at  birth,  or  had  been  subse- 
quently produced.  Among  the  former  may  be  placed 
such  examples  as  depend  upon  congenital  stenosis, 
upon  certain  congenital  deformities,  upon  Meckel's 
diverticulum,  upon  peritoneal  bands  the  result  of 
intra-uterine  peritonitis,  and  the  like.  Among  the 
latter  would  be  grouped  cases  of  stricture  following 
ulceration,  intussusception,  volvulus,  strangulation  by 
bands  produced  by  peritonitis,  cases  of  obstruction  by 
foreign  bodies,  and  indeed  all  the  principal  examples 
of  intestinal  occlusion. 

By  another  method  the  classification  is  founded 
upon  a  discrimination  of  the  different  mechanical 
conditions  that  produce  the  narrowing  or  closure  of 
the  lumen  of  the  bowel.  Thus  in  one  set  of  cases  the 
lumen  of  the  canal  is  obliterated  by  j^'^^ssiore  froin 
without.  This  division  would  include  all  cases  of 
strangulation  by  bands  and  through  apertures,  and  all 
examples  of  obstruction  by  the  pressure  of  a  tumour 
B— 12 


2  Intestinal  Obstruction.  [Chap.  i. 

outside  the  bowel.  In  another  set  of  cases  the  intes- 
tine is  occluded  in  consequence  of  an  alteration  in  its 
normal  outline  and  in  the  relation  that  its  walls  bear 
the  one  to  the  other.  Under  this  headins:  would  be 
classed  examples  of  volvulus,  of  occlusion  by  kinking 
and  bending,  and  the  important  series  of  cases  known 
as  intussusceptions.  In  a  third  variety  of  case  the 
lumen  of  tlie  howel  is  blocked  by  some  substance  such 
as  a  foreign  body  that  has  been  swallowed,  a  gall 
stone,  an  enterolith,  a  mass  of  ftecal  matter,  or  a 
neoplasm  growing  from  the  intestinal  wall.  In  a 
still  further  series  of  cases  the  obstruction  depends 
upon  changes  arising  in  the  wall  of  the  gut  itself 
and  under  this  heading  we  meet  with  stenoses  and 
strictures  of  all  kinds,  including  both  those  that  are 
simple  and  those  that  are  cancerous. 

By  a  third  method  of  classification  all  cases  are 
divided  according  to  their  clinical  character  and  are 
grouped  into  acute  and  subacute  cases,  into  chronic 
cases  and  into  chronic  cases  that  end  acutely.  This 
division  of  the  subject  has  been  adopted  in  that  part 
of  the  present  volume  which  deals  Avith  the  general 
subject  of  diagnosis. 

Lastly  there  is  a  method  of  classification  based 
upon  2J(ithological  anatomy.  This  is  the  method  that 
has  been  followed  in  the  body  of  the  present  work. 

This  plan  consists  in  grouping  together  instances 
of  intestinal  obstruction  tliat  are  pathologically  alike. 
It  consists  of  such  an  arrangement  and  grouping  as 
would  probably  be  adopted  if  all  the  specimens  of 
intestinal  obstruction  in  anv  larcje  museum  were 
taken,  and  an  attempt  then  made  to  arrange  them  in 
some  definite  and  coherent  order.  The  classification 
that  is  founded  upon  this  basis  is  the  following : 

Strangulation  by  bands,  etc.,  or  through  apertures. 

Volvulus. 

Intussusception. 


Chap.  II.]  Etiology. 

Stricture. 

Obstruction  by  neoplasms. 

Compression  by  tumours,  etc.,  external  to  the  bowel. 

Obstruction  by  gall  stones  and  foreign  bodies. 

Obstruction  by  enteroliths. 

Obstruction  by  fsecal  masses. 


CHAPTEE  IT. 

SOME    ESPECIAL    FEATUKES    IN    THE    ETIOLOGY    OF 
INTESTINAL    OBSTRUCTION. 

Into  the  very  wide  and  complicated  subject  of  the 
general  etiology  of  intestinal  obstruction  I  do  not 
propose  to  enter  in  this  place,  since  the  more  impor- 
tant features  in  the  causation  of  the  various  forms  of 
stoppage  of  the  bowels  are  detailed  in  the  account 
given  of  those  diflerent  forms  when  considered 
individually. 

There  are,  however,  certain  phases  of  the  matter 
that  are  well  worthy  of  a  separate  consideration  upon 
special  grounds,  and  among  these  may  be  taken  the 
influence  of  the  following  affections  in  producing 
intestinal  obstruction,  viz.: 

Peritonitis. 
Sti-angulated  hernia. 
IMescnteric  gland  disease. 

The  important  subject  of  the  influence  of  ulcera- 
tion of  the  intestine  in  producing  occlusion  is  fully 
considered  in  the  chapter  on  stricture. 

Peritonitis. — It  is  well  known  that  in  this 
affection,  and  especially  in  what  is  known  as  the 
adhesive  form,  a  fibrinous  exudation  appears  upon 
the  surface  of  the  inflamed  membrane.  Any  two 
surfaces  so  affected  may,  through  the  medium  of  the 


4  Intestinal  Obstruction.         [Chap.  ii. 

exudation,  become  adherent  if  they  be  brought  into 
contact  with  one  another. 

The  adhesion  may  be  over  a  very  extensive  sur- 
face, or  may  involve  only  a  few  isolated  points.  As 
the  inflammation  subsides  there  is  no  doubt  that  a 
good  deal  of  this  exudation  is  in  time  absorbed. 
Such  as  remains  becomes  organised  into  fibrous  tissue, 
and  so  are  produced  "  adhesions,"  "  bands,"  "  perito- 
neal false  ligaments,"  and  the  like. 

Some  of  these  adhesions  may  be  extremely  loose 
and  delicate,  while  others  are  composed  of  a  more 
callous  material.  It  would  appear  that  many  of  the 
more  flimsy  of  these  uniting  structures  in  time  disap- 
pear, even  after  they  have  become  organised  into 
definite  connective  tissue.  It  is  much  to  be  regretted 
that  so  little  is  known  of  the  circumstances  that 
favour  the  absorption  of  adhesions  after  peritonitis, 
and  so  an  important  element  in  the  prognosis  of  that 
affection  is  lackino;.  One  circumstance  that  has 
distinct  influence  in  this  direction  is  certainly  the 
movement  of  the  adhering  pai-ts.  As  an  illustration 
of  this  might  be  taken  adhesions  that  involve  the 
small  intestine,  and  that  are  connected  with  that 
bowel  either  by  both  of  their  points  of  attachment  or 
by  one. 

During  the  progress  of  peritonitis  the  intes- 
tines are  relatively  still.  They  are,  moreover,  more 
or  less  distended  from  some  paralysis  of  their  walls. 
As  a  result  of  this  distension  coils  of  bowel  may 
be  brought  together  that  were  hitherto  far  apart,  or  a 
certain  loop  may  be  placed  in  association  with  a  com- 
paratively distant  point  on  the  parietes.  When  the 
inflammation  has  subsided  the  parts  return,  as  far 
as  possiljle,  to  the  status  quo  ante,  peristaltic  move- 
ments spread  through  the  intestine,  coils  that  were 
close  together  tend,  as  a  result  of  those  movements, 
to  become  separated,  and  adhesions  that  attach  the 


Chap.  II.]  Etiology.  5 

intestine  to  points  upon  the  parietes  are  persistently 
dragged  upon.  It  follows  from  tliis  almost  constant 
tension  that  the  still  soft  adhesion  yields,  becomes 
elongated  and  thinned,  ultimately  gives  way  and  is 
absorbed. 

Movement  also  has  great  influence  upon  the 
future  physical  characters  of  the  adhesion.  Most  of 
the  adhesions  assume  primarily  a  membranous  cha- 
racter, and  this  they  may  retain  throughout  their 
existence.  It  is  not  uncommon  to  find  some  coils  of 
intestine  matted  together  by  an  extensive  series  of 
false  membranes,  which  appear  sometimes  as  wide 
expansions,  at  other  times  as  thin  but  broad  ribbon- 
like bandsj  of  all  dimensions  and  of  various  lengths 
(Figs.  1  and  24).  If  two  distant  coils  of  small  intes- 
tine have  been  brought  together  during  peritonitis, 
and  have  become  attached  to  one  another  by  means  of 
the  exudation,  or  if  a  like  attachment  has  taken  place 
between  the  intestine  and  the  parietes,  then,  as  move- 
ment is  restored  in  the  bowel,  the  adhesions,  which 
may  be  quite  membranous,  are  dragged  upon,  and 
as  a  result  become  elongated.  As  they  increase  in 
length  so  must  they  become  attenuated  in  width  and 
thickness.  The  constant  tension,  moreover,  probably 
interferes  with  their  already  feeble  nutrition,  and 
induces  a  further  wasting. 

The  wide  membranous  adhesion  may  thus  become 
narrowed  and  ribbon-like. 

It  may,  however,  undergo  a  still  further  change. 
This  adhesion,  subjected  to  the  rolling  movements  of 
the  intestines  over  one  another,  and  subjected  to  fre- 
quent tortion,  now  in  one  direction  and  now  in  the 
other,  tends  to  become  rounded  and  cord-like,  and 
the  more  that  it  is  stretched  the  more  completely  is 
this  transformation  favoured.  Thus  are  formed 
"  peritoneal  false  ligaments  "  and  the  bands  that  are 
so  common  a  cause  of  strangulation  of  the  bowel. 


6  Intestinal  Obstruction.  [Chap.  ii. 

The  moulding  of  the  mass  of  adhesion-tissue  into 
a  cord  by  the  movements  active  within  the  abdomen 
is  illustrated  by  the  changes  that  are  effected  by 
those  movements  in  the  omentum  when  it  becomes 
adherent.  This  structure  may  become  attached  by 
its  free  extremity,  and  in  the  course  of  time,  if  the 
abdomen  be  opened,  it  will  be  found  to  be  changed 
into  a  cord-like  mass.  The  intestines  in  their  move- 
ments have  rolled  over  and  under  and  about  the 
adherent  membrane,  and  at  last  they  have  moulded 
it  almost  as  a  piece  of  clay  may  be  moulded  when 
rubbed  betweeli  the  palms.  This  change  is  best 
brought  about  when  the  situation  of  the  adhesion  is 
such  as  to  keep  the  membrane  on  the  stretch. 

A  like  metamorphosis  may  be  effected  in  any 
smaller  part  of  the  great  omentum  that  may  have 
become  adherent  to  a  distant  point. 

By  a  combination  of  these  various  circumstances, 
by  a  stretching  of  the  adhesion  on  the  one  hand,  by 
its  consequent  attenuation  on  the  other,  and  its 
subjection  to  the  moulding  influences  of  moving 
intestines  for  the  third  part,  it  happens  that  cords 
and  bands  of  great  length  are  often  produced  as  a 
result  of  peritonitis.  Many  instances  may  be  given, 
but  one  of  the  most  striking  is  afforded  by  a  case 
reported  by  Mr.  Obre."^  In  this  example  a  cord-like 
band  was  found  to  pass  from  a  coil  of  small  intestine 
situated  near  the  xiphoid  cartilage  to  the  parietal 
peritoneum  about  the  inguinal  canal.  The  false 
ligament  measured  seventeen  and  a  half  inches.  The 
patient  had  had  a  strangulated  inguinal  hernia,  and 
there  was  clear  evidence  to  show  that  the  herniated 
bowel  had  been  that  to  which  the  cord  was  attached. 
Subsequent  changes  in  the  abdomen,  which  were  asso- 
ciated with  much  violent  peristaltic  movement  and 
much  distension,  had  carried  the  involved  coil  so  far 
*  Path.  Soc.  Trans.,  vol.  iii.,  page  95. 


Chap.  II.]  Etiology.  7 

away  from  its  original  point  of  adhesion  as  to  produce 
the  band  described. 

It  must  be  remembered  that  not  only  may  these 
Ijands  form  arcades  beneath  which  coils  of  intestine 
may  become  strangulated,  but  the  longer  of  them 
may  become  separated  at  one  of  their  points  of 
attachment,  and  so  form  floating  cords  that  may  lead 
to  strangulation  of  a  loop  by  "  knotting." 

Adhesions  of  all  kinds,  but  especially  those 
attached  to  parts  not  susceptible  of  much  movement, 
may  undergo  considerable  contraction.  In  cases  of 
extensive  peritonitis  this  contraction  may  produce 
great  deformity.  The  mesentery  may  become  so 
shrunken  as  to  produce  obstruction  in  the  intestine  to 
which  it  is  attached.  The  most  severe  form  of  this 
condition  is  that  known  as  peritonitis  deformans. 

Adhesions  upon  the  surface  of  a  fixed  part  of  the 
intestine  may,  as  a  result  of  their  contraction,  pro- 
duce great  narrowing  of  the  bowel  by  compressing  it. 
This  condition  is  not  infrequently  met  with  in  the 
colon,  and  especially  in  the  hepatic  and  splenic 
flexures  (Fig.  22).  In  parts  of  the  tube  where  the  gut 
cannot  be  compressed  against  an  unyielding  surface 
the  contraction  of  peritoneal  adhesions  may  still 
produce  some  obstruction  by  causing  an  extensive 
puckering  of  the  intestinal  walls. 

Some  of  the  adhesions  formed  after  inflammation 
oJt  the  serous  membrane  are  exceedingly  complicated, 
while  others  are  found  to  unite  parts  that  are  usually 
far  separated  from  one  another.  Thus  I  find  in- 
stances of  adhesion  between  the  ascending  colon  and 
the  ovary,  between  the  transverse  colon  and  the 
csecum  in  one  case,  and  the  mesentery  over  the  lower 
lumbar  region  ii^  another,  between  the  arch  of  the 
colon  and  a  part  of  the  parietes  not  far  above  the 
symphysis.  Then  again  the  sigmoid  flexure  has  been 
found   connected   by  adhesions   to   the   bladder,    the 


8  Intestinal  Obstruction.  [Chap.  ii. 

uterus,  the  rectum,  the  peritoneum  in  the  right  iliac 
fossa,  and  the  csecum.  In  all  these  cases  I  tliink  that 
the  unusual  connection  of  parts  may  be  explained  by 
displacement  from  distension,  the  distension  occurring 
duiing  the  development  of  the  peritonitis.  Thus  the 
transverse  colon  when  distended  is  apt  to  become 
bent  uj^on  itself,  and  by  such  bending  to  reach  the 
lower  parts  of  the  abdomen.  In  the  same  way  the 
distended  sigmoid  flexure  may  turn  down  into  the 
pelvis,  or  extend  across  to  the  right  iliac  region,  or 
even  mount  up  in  the  abdomen  and  reach  the  liver. 

In  addition  to  the  causes  of  obstruction  already 
alluded  to,  peritonitis  may  be  the  means  of  bringing 
about  an  occlusion  in  the  intestine  by  other  and  very 
difterent  methods. 

The  adhesions  may  form  a  part  of  the  bowel  into 
a  rigid  loop,  they  may  bend  it  so  acutely  as  to  greatly 
narrow  or  even  entirely  obstruct  its  lumen,  they  may 
lead  to  obstruction  by  kinking,  or  they  may  bring 
about  an  arrangement  of  certain  coils  of  small  intes- 
tine or  of  the  loop  of  the  sigmoid  flexure  that 
especially  favours  the  production  of  a  volvulus. 

In  another  series  of  cases  as  a  result  of  local 
peritonitis,  the  omentum  or  the  tip  of  the  appendix 
vermiformis  has  become  adherent  at  one  point,  and 
beneath  the  arcade  so  formed  coils  of  intestine  have 
been  strangulated.  Similar  arcades  have  been 
formed  by  the  adhesion  of  the  point  of  a  free 
Meckel's  diverticulum,  and  of  the  outer  extremity  of 
the  Fallopian  tube. 

In  still  another  variety  of  case  a  loop  of  bowel 
has  been  strangulated  through  a  slit  in  a  membranous 
adhesion,  or  through  an  aperture  formed  by  adhesions 
between  adjacent  viscera,  or  through  the  gap  left 
between  two  parallel  adhesions. 

With  regard  to  the  forms  of  peritonitis  that  may 
lead    to  adhesions  capable  of  producing   obstruction, 


Chap.  II.]  Etiology.  9 

it  can  be  briefly  said  that  any  variety  of  peritoneal 
inflammation  from  wliicli  a  patient  recovers  may 
become  indirectly  a  cause  of  intestinal  occlusion.  In 
the  great  majority  of  cases,  therefore,  it  will  be  found 
to  have  been  a  very  localised  peritonitis.  The  prin- 
cipal examples  are  furnished  by  the  circumscribed 
pelvic  peritonitis  that  is  comparatively  so  common  in 
women,  by  that  attending  typhlitis  or  perityphlitis, 
by  that  depending  upon  injury,  or  upon  an  ulceration 
of  the  stomach  or  intestine  that  has  not  quite  ad- 
vanced to  perforation.  Another  common  form  has 
followed  upon  strangulated  hernia.  Another  has 
been  induced  by  gall  stones,  and  has  led  probably  to 
adhesion  between  the  gall  bladder  and  the  colon. 
Another  has  been  set  up  by  faecal  accumulations,  or 
by  the  impaction  of  some  foreign  substance  in  the 
bowel. 

It  must  be  remembered  also  that  peritonitis  may 
occur  during  intra-uterine  life.  Dohrn,  indeed,  rei^oits 
a  case  of  obstruction  in  a  child  eight  days  old  that 
ended  fatally,  and  was  found  to  be  due  to  adhesions 
formed  evidently  before  birth. ''^ 

There  is  also  a  form  of  peritonitis  that  may  occur 
shortly  after  birth,  and  that  appears  to  be  due  to 
extension  of  inflammation  from  the  divided  umbilical 
cord. 

The  variety  of  peritonitis  known  as  "  infantile," 
and  which  is  distinct  from  the  localised  form  just 
mentioned,  is  with  very  rare  exceptions  always  fatal, 
and  in  the  newly  born  would  appear  to  be  without 
exception  fatal. 

Acute  diflfused  peritonitis  is  so  very  seldom  re- 
covered from  that  it  can  have  little  concern  in  the 
etiology  of  obstruction.  In  puerperal  peritonitis, 
according   to    Bauer,   "an  absolutely  fatal  prognosis 

*  Quoted  by  Bauer  ;  Ziemsson's  Cyclopaedia  of  Medicine,  vol. 
viii.,  page  288. 


lo  Intestinal  Obstruction.  [Chap.  ii. 

must  be  made,"  and  the  same  gloomy  prognosis 
applies  to  the  j^eritonitis  depending  upon  carcinoma. 

With  regard  to  tubercular  peritonitis,  it  leads  in 
time  to  a  certain  death ;  but  its  coui-se  is  usually 
chronic,  and  during  its  progress  it  is  apt  to  produce 
very  numerous  and  extensive  adhesions,  which  are 
frequently  the  cause  of  intestinal  obstruction.  Indeed, 
certain  writers  have  included  chronic  tubercular  peri- 
tonitis among  the  varieties  of  chronic  occlusion  of 
the  bowels. 

StraiigTilatcd  hernia.— There  is,  I  think,  a 
fairly  common  impression  that  when  a  strangulated 
hernia  has  been  reduced  and  the  patient  has  recovered 
from  the  operation,  no  further  evils  will  result  beyond 
a  possible  return  of  the  hernia,  and  with  it  a  risk  of 
a  second  strangulation.  A  piece  of  bowel,  however, 
that  has  been  strangulated  in  an  external  hernia  and 
has  then  been  reduced  into  the  abdomen  may  be  the 
cause  of  one  of  many  different  forms  of  intestinal 
obstruction.  I  do  not  allude  to  results  immediately 
following  the  reduction  of  the  hernia,  but  to  results 
that  are  comparatively  remote.  Among  the  former, 
as  is  well  known,  it  is  not  infrequent  for  the  once 
strangulated  loop  to  remain  so  entirely  paralysed 
after  reduction  as  to  continue  the  symptoms  of  ob- 
struction until  death  ensues,  and  that,  too,  without 
either  becoming  gangi-enous  or  causing  peritonitis.* 

The  conditions  Avith  which  I  propose  to  deal 
briefly  are  remote,  and  are  subsequent  to  the  more  or 
less  complete  recovery  of  the  patient  from  the  opera- 
tion. 

1.  The  peritonitis  about  the  reduced  loop  of  bowel 
may  lead  to  adhesions,  and  these  may  cause  obstruction 

*  See  cases  by  Mr.  Pitts,  St.  Thomas's  Hosp.  Repoi-ts,  1882, 
page  75  ;  and  Hemot  (Pseudo-etranglements,  page  4G).  For  a 
general  consideration  of  the  immediate  effects  that  may  follow 
reduction,  sec  "  Les  Accidents  consecutifs  a  la  Reduction  de 
I'Euteroc^le  <^trangl^e,"  by  Jules  Ferret.     Th6se.     Paris,  1879. 


Chap.  II. J  Etiology.  ii 

by  kinking  or  bending  of  the  gut.  On  the  otlier 
liiind,  the  oincntnin  or  a  free  coil  of  intestine  may 
become  adherent  to  the  inflamed  serous  surface,  and 
thus  a  condition  be  produced  that  may  lead  to  ob- 
struction."*^ 

2.  The  reduced  loop  may  adhere  to  the  abdominal 
parietes  and  become  obstructed  by  bending  and  by 
the  changes  known  as  "  traction  effects."  Examples 
of  this  form  of  obstruction  are  given  in  chapter  vi. 

3.  The  ad  hesions  about  the  reduced  and  adherent 
loop  may  be  extensive,  and  may  so  contract  as  to 
narrow  the  lumen  of  the  gut  by  compression. 

4.  The  herniated  coil  may  be  retained  in  the 
form  of  a  permanent  loop  by  means  of  adliesions,  and 
this  loop,  whether  an  "  open  "  or  a  "  closed  "  one,  may 
lead  to  obstruction  of  the  intestine,  as  is  fully  ex- 
plained in  a  subsequent  part  of  this  work. 

In  one  instance  at  least  a  fistula  bimucosa  was 
formed  between  the  extremities  of  the  loop. 

5.  Stricture  may  follow  as  a  result  of  damage  to 
the  walls  of  the  bowel,  ulceration  of  the  mucous 
membrane,  and  the  like.  Several  illustrations  of  this 
condition  will  be  found  in  the  chapter  upon  cicatricial 
strictuVe. 

C.  The  great  lengthening  of  the  mesentery  that 
is  usually  found  in  large  hernia?  favours  especially 
the  formation  of  volvulus  of  the  small  intestine.  The 
connection  between  these  two  conditions  is  well 
shown  in  a  case  reported  by  Dr.  J.  K.  Fowler,  where 
tliere  is  little  doubt  but  that  a  fatal  volvulus  of  the 
ileum  depended  upon  an  unduly  long  mesentery  re- 
sulting from  hernia,  t 

*  Bull,  (le  la  Soc.  Anat.,  1804,  page  252 ;  M.  Besnier.  See 
also  Patli.  Soc,  Trans.,  vol.  vii.,  ])age  11)8  ;  Mr.  Obro. 

i'  For  a  further  account  of  this  matter  sec  a  paper  by  the 
author  on  "The  Forms  of  Intestinal  Obstruction  that  may  follow 
after  Hernia  "  [Lancet^  Juno  7,  1884). 


T2  Intestinal  Obstruction.  [Chap.  ii. 

Mesenteric  g:l»iid  disease.— Mesenteric  gland 
disease  may  indirectly  lead  to  obstruction  in  several 
different  ways. 

1.  The  little  local  peritonitis  excited  in  tlie  serous 
membrane  covering  the  glands  may  lead  to  the  adhe- 
sion of  a  free  diverticulum,  or  of  the  free  end  of  the 
omentum,  or  may  encourage  the  development  of 
bands  which  may  in  turn  prove  a  cause  of  intestinal 
stranojulation.  * 

2.  The  local  peritonitis  may  lead  to  adhesions 
being  formed  between  two  remote  parts  of  the  intes- 
tinal tube.  Thus,  in  a  case  recorded  by  Dr.  Hilton 
Fagge  the  sigmoid  flexure  was  found  attached  to  the 
ileum,  and  in  the  angle  between  these  two  adherent 
portions  of  gut  was  a  caseous  gland.  + 

3.  The  ileum  about  the  seat  of  a  diseased  gland  in 
the  mesentery  may  become  sharply  bent  upon  itself ; 
and  between  the  two  limbs  of  the  loop  so  formed,  and 
fusing  them  together,  as  it  were,  will  usually  be  found 
an  old  and  degenerate  gland. 

Or  the  bending  may  be  very  limited  and  well 
localised,  so  that  a  fold  of  the  bowel  is  turned  in  and 
forms  a  sjoecies  of  diaphragm.  This  condition  is 
shown  in  the  remarkable,  and,  I  think,  unique,  case 
depicted  in  Fig.  49. 

4.  In  several  instances  the  shrinking  of  the 
mesentery  after  extensive  gland  disease  has  been  so 
considerable,  and  has  produced  so  much  distortion,  as 
to  lead  to  a  fatal  obstruction  of  that  part  of  the  bowel 
connected  with  the  diseased  area.;}; 

5.  Dr.  Leared  has  reported  a  case  of  fatal  stran- 

*  Bee  specimens,  Guy's  Hosp.  Museum,  No.  1,819  (36) ;  and 
St.  Bart.'s  Hosp.  Museum,  No.  2,105  ;  also  cases  by  M.  Briclieteau 
(Bull,  de  la  Soc.  Anat.,  1861,  page  118),  and  by  Mr.  B.  Hill  {Lancet, 
vol.  i.,  1876,  page  773). 

f  Path.  Soc.  Trans.,  vol.  xxvii.,  page  1.57. 

j  See  Path.  Soc.  Trans.,  vol.  xxi.,  page  187  ;  and  cases  by 
Dr.  Fagge,  Guy's  Hosj).  lleports,  vol.  xiv.,  page  272. 


Chap.  III.]        Strangulation  BY  Bands.  13 

gulation  of  tlie  small  intestine  through  a  hole  in  the 
mesentery.  It  was  considered  that  this  aperture  was 
probably  caused  by  the  breaking  down  of  a  mesen- 
teric gland.     The  patient  was  a  lad  aged  14."^ 


CHAPTER    III. 

STKANGULATION    BY    BANDS    OK    THROUGH   APERTURES 

HERNIA-LIKE    STRANGULATION    OF    THE    BOWEL. 

Under    this  variety  of    intestinal    obstruction    may 
be  included  : 

1.  Strangulation  by  isolated  peritoneal  adhesions, 

2.  Strangulation  by  cords  formed  from  tbe  omentum. 

3.  Strangulation  by  Meckel's  diverticulum. 

4.  Strangulation  by  normal  structures  abnormally  attached 

(such,  as  by  an  adherent  vermiform  appendix  or  Fallo- 
pian tube,  or  by  a  fixed  mesentery) ,  including  strangu- 
lation by  the  pedicle  of  an  ovarian  tumour  and  the 
hke. 

5.  Strangulation  through  slits  and  apertures  in  the  mesen- 

tery or  omentum,  or  in  certain  peritoneal  Hgaments, 
or  through  membranous  adhesions. 

These  various  forms  may  be  conveniently  con- 
sidered together,  for  although  in  each  case  the 
anatomical  cause  of  the  obstruction  is  different,  yet 
the  effects  upon  the  gut  are  in  all  instances  practi- 
cally identical.  In  each  the  segment  of  bowel  in- 
volved is,  almost  without  exception,  the  small 
intestine.  In  each  the  mechanism  of  the  obstruction 
is  practically  the  same.  In  each  the  symptoms  that 
arise  are,  with  some  minute  exceptions,  so  nearly 
identical  that  they  may  be  studied  as  a  whole.  In 
each  the  course  and  issue  of  the  malady  are  such  that 

*  Path.  See.  Trans.,  vol.  xiv.,  page  156. 


1 4  InTES  TINA  L    ObS  TR  UC  TION.  [Chap.  1 1 1 . 

these  various  forms  may  be  said  to  share  a  common 
prognosis.  Between  them  all,  moreover,  there  is  a 
close  bond  of  union  in  the  fact  that  they  are  adapted 
for  the  same  form  of  treatment,  and  may  be  relieved 
by  the  same  operative  procedures. 

Considered  as  a  whole  this  form  may  be  taken  as 
the  type  of  acute  intestinal  obstruction,  and  as  such 
it  assumes  a  position  of  considerable  importance.  It 
is  the  strangulated  hernia  of  the  interior  of  the 
abdomen.  It  obstructs  the  gut  as  a  hernia  obstructs. 
It  involves  the  small  intestine  with  about  the  same 
frequency  as  does  an  external  rupture.  It  is  indeed 
as  rare  to  find  a  portion  of  the  large  intestine  stran- 
gulated by  any  of  the  methods  above  named,  as  it  is 
to  discover  colon  in  a  femoral  or  inguinal  hernia. 
The  symptoms  that  attend  this  variety  of  intestinal 
obstruction  are,  in  all  main  points,  the  symptoms  of 
strangulated  hernia,  and  the  prognosis  of  the  two 
affections  depends  rather  upon  the  situation  of  the 
constricting  agent  than  upon  any  other  factor.  It  is 
for  many  reasons  a  matter  of  moment  to  note  that 
strangulated  hernia  and  the  different  forms  of 
internal  obstruction  above  described  are  but  varieties 
of  a  single  malady,  that  they  differ  from  one  another 
solely  on  anatomical  grounds,  that  in  their  pathology 
and  in  the  broader  lines  of  their  clinical  history  they 
are  the  same,  and  that,  excluding  the  taxis,  they  are 
amenable  to  the  same  general  form  of  surgical  treat- 
ment. 

It  will  be  convenient  to  consider  the  pathological 
anatomy  of  these  five  varieties  of  obstruction  separ- 
ately, and  then  their  symptoms  and  the  elements  of 
their  prognosis  collectively. 

PATHOLOGICAL    ANATOMY. 

1.  Strangulation  by  isolated  peritoneal 
adhesions.— Those  isolated  adhesions  (known  com- 


Chap.  III.]        Strangulation  BY  Bands.  15 

monly  as  "bands,"  "solitary  bands,"  or  "peritoneal 
false  ligaments  ")  are  the  results  or  residues  of  some 
form  of  peritonitis.  Owing  to  tlie  high  mortality  of 
acute  diffused  peritonitis  on  the  one  hand,  and  the 
very  general  and  extensive  adhesions  produced  by 
chronic  diffused  peritonitis  on  the  other,  it  follows  that 
these  isolated  bands  are  usually  due  to  moderate, 
chronic,  and  well  localised  forms  of  peritoneal  inflam- 
mation. It  would  appear,  as  has  been  already  pointed 
out,  that  in  some  cases  they  may  be  congenital,  and 
due  then  to  intra-uterine  peritonitis.  The  mode  of 
formation  of  these  bands,  and  the  methods  whereby 
they  become  elongated  and  cord-like  have  already 
been  described  (chapter  ii.). 

Their  appearance  in  cases  where  they  have  caused 
obstruction  varies  greatly. 

Most  commonly  the  "  band ''  takes  the  form  of  a 
firm  fibrous  cord  about  the  size  of  a  No.  4  or  No.  6 
catheter.  It  may  be  still  more  slender,  and  appear 
as  a  tough,  rigid  thread.  On  the  other  hand,  it  may 
be  of  comparatively  large  size ;  thus  M.  Terrier  has 
reported  a  case  of  internal  strangulation,  for  which 
he  performed  laparotomy,  where  the  constricting 
band  had  nearly  the  dimensions  of  the  little  finger.* 
The  cord-like  "  band  "  is  usually  described  as  being 
dense  and  fibrous,  and  in  one  or  two  instances  as 
being  of  almost  cartilaginous  hardness.  Less  fre- 
quently the  constricting  agent  has  the  appearance  of 
an  actual  l)and,  and  in  such  cases  is  found  as  a  tough 
ribbon-like  membrane,  with  a  width  of  half  an  inch  or 
even  more.  A  band  of  this  character  is  well  shown 
in  Fig.  1. 1 

The  "  false  ligament "  is  usually  single,  and  hence 
the  name  bestowed  upon  it   by    Mr.    Gay   of    "the 

*  Bull,  ct  Mem  de  la  Soc.  dc  Chir.  de  Taris,  vol.  iv.,  1879, 
page  5G4. 

t  London  Hosp.  Museum,  No.  Ad.  78. 


1 6  Intestinal  Obstruction.         [Chap.  hi. 

solitary  band."  It  must  not  be  assumed,  however, 
tliat  such  a  band  commonly  exists  as  the  solitary 
adhesion  in  any  given  case.  It  most  probably  will  be 
the  only  isolated  adhesion,  and  the  only  one  so 
modified  as  to  be  capable  of  strangulating  the  bowel. 
But  in  cases  where  this  isolated  adhesion  is  met  with 
other  adhesions  will  very  usually  be  found.     This  is 


Fig.  1.— Strangulation  by  a  broad  Pei-itoueal  Baud  passing  between  two 
adjacent  Coils  of  Ileum. 

especially  the  case  when  the  band  is  due,  as  it  often 
is,  to  pelvic  peritonitis.  The  same  ajiplies,  although 
in  a  less  degree,  to  the  local  peritonitis  set  up  by 
inflammation  in  or  about  the  caecum.  Here,  in  addi- 
tion to  any  adhesion  that  may  have  become  isolated, 
elongated,  and  cord-like,  there  will  very  probably  be 
some  matting  together  of  parts  in  the  immediate 
vicinity  of  the  caput  coli.  ^lany  cases,  however,  are 
reported  wliere  the  only  relics  of  a  typhlitis  have 
assumed  the  form  of  one  solitary  band,  A  single 
false  ligament,  the  representative  of  a  single  adhesion, 


Chap. III.]       Strangulation  BY  Bands.  17 

may  be  produced  by  the  very  localised  peritonitis  that 
is  sometimes  associated  with  caseous  degeneration  of 
a  mesenteric  gland.  I  have  met  with  several  re- 
ported cases,  and  not  a  few  specimens,  that  illustrate 
this  circumstance.  A  single  adhesion  may  readily 
follow  upon  the  little  speck  of  peritonitis  that  often 
attends  an  intestinal  ulcer  (Fig,  20).  As  the  ulcer 
deepens  it  excites  an  inflammation  over  a  very 
limited  area  of  the  serous  surface.  This  inflamed 
spot  adheres  to  some  other  point  on  the  peritoneum  ; 
a  single  adhesion  forms,  which,  becoming  elongated  by 
the  method  already  described,  forms  an  example  of 
the  solitary  band.  A  great  many  of  the  cases  of 
"  solitary  band  "  described  are  evidently  instances  of 
strangulation  by  Meckel's  diverticulum,  or  by  a  diver- 
ticular ligament. 

In  some  few  cases  there  have  been  two  or  more 
false  ligaments  found  in  the  abdominal  cavity.  ,  Some- 
times these  would  a})pear  to  have  been  produced  by 
the  thrusting  of  a  coil  of  intestine  through  a  broad 
peritoneal  adhesion  so  as  to  divide  it  into  two  seg- 
ments. In  other  instances  the  bands  are  inde])endent 
of  one  another.  Mr.  Berkeley  Hill  reports  a  case  of 
acute  intestinal  obstruction  where  two  bands  existed, 
both  of  which  constricted  knuckles  of  small  intestine. 
One  constriction  was,  however,  comparatively  slight, 
the  other  was  severe.  Laparotomy  was  performed, 
and  unfortunately  the  band  found  and  divided  was 
that  associated  with  the  minor  obstruction.  The 
more  serious  strangulation  was  overlooked  and  the 
child  died.  The  adhesions  in  this  case  appear  to  have 
been  due  to  mesenteric  gland  disease.* 

The  false  ligament,  although  single,  may  have  a 
complicated  arrangement,  and  lead  to  extraordinary 
forms  of  constriction    of   the    bowel.      Thus    in    the 


*  Lancet,  vol.  i.,  1876,  page  773. 
1  ^ 

-1  A< 


i8 


Intestina  l  Obs  tr  uc tion. 


[Chap.  III. 


specimen  shown  in  Fig.  2  "^  there  was  one  isolated  adhe- 
sion. It  was,  however,  broad  and  Y-shaped  ;  one  end 
of  the  Y  was  attached  to  the  uterus,  while  the  two 
other  ends  were  connected  with  points  on  the  small 


Fig.  2.— strangulation  of  the  Ileum  by  a  Y-sliaped  Band  attached  to  the 

Fundus  of  the  Uterus. 

The  Uterus  is  shown  at  the  lower  part  of  the  figure. 

intestine  about  one  and  a  half  inches  apart.  Tliere 
were  many  adhesions  about  the  pelvic  viscera.  In 
Fig.  3  t  it  will  be  seen  that  an  adhesion  connecting  the 

*  St.  Bart.'s  Hosp.  l\Iuseum,  No.  2,164. 
t  Guy's  Hosp.  Museum,  No,  2,507  (50). 


Chap.  III.]        Strangulation  by  Bands, 


19 


Fig.  3.— Strangulation  of  tbe  Ileum  by  complicated  Bands  passing  be- 
tween the  Uterus  and  Ovary. 

uterus,  ovary,  and  mesentery  leads  to  a  complicated 
form  of  strangulation  and  to  a  double  constriction 
of  the  bowel. 


20  Intestinal  Obstruction.         [Chap.  iii. 

In  many  cases  of  strangulation  by  a  false  liga- 
ment the  circumstances  of  the  obstruction  are  com- 
plicated by  simple  adhesions  of  the  same  age,  and  due 
to  the  same  cause,  as  the  so-called  ligament.  These 
adhesions  may  have  matted  together  into  a  knuckle 
the  very  segment  of  the  bowel  that  has  become 
strangulated,  or  may  have  so  attached  themselves  to 
the  involved  intestine  as  to  encourage  a  volvulus  of 
it  wlien  beneath  the  constricting  band. 

The  attachments  of  these  peritoneal  false  liga- 
ments exhibit  the  greatest  possible  variety.  To  be 
capable  of  producing  a  strangulation  of  the  intestine 
the  band  must  have  at  least  two  points  of  attach- 
ment, and  there  is  scarcely  any  conceivable  combina- 
tion of  connected  points  that  is  not  illustrated  in  the 
history  of  these  adhesions. 

Most  commonly  the  strangulating  band  is  con- 
nected by  one  end  with  the  mesentery.  In  one  very 
frequent  variety  the  band  is  attached  by  both  its 
extremities  to  the  mesentery,  the  points  of  attach- 
ment being  at  a  variable  distance  apart.  This 
disposition  of  the  band  is  illustrated  by  Fig.  4,*  and 
it  would  ajDpear  to  be  very  frequently,  if  not  most 
frequently,  due  to  a  limited  peritonitis  incident  upon 
mesenteric  gland  disease.t  In  that  very  large  series 
of  cases  where  the  isolated  adhesion  is  due  to  pelvic 
peritonitis,  it  may  be  found  to  be  attached  by  one 
end  to  some  pelvic  viscus,  and  by  the  other  to  a 
neighbouring  part.  Thus  bands  are  found  passing 
from  the  uterus,  or  ovary,  or  bladder,  to  the  parietal 
peritoneum  of  the  pelvis  or  abdomen ;  or,  starting 
from  the  same  source,  they  may  attach  themselves  to 
the  csecum  or  sigmoid  flexure,  or  with  much  greater 
frequency  to   some  part    of    the  lower  ileum   or  its 

*  University  Coll.  Museum,  No.  1,164. 

t  See  specimens  St.  Bart.'s  Hosp.  Museum,  No.  2,165 ;  and 
Lend.  Hosp.  Museum,  No.  Ad.  79. 


Chap.  III.]        Strangulation  BY  Bands. 


21 


mesentery.  In  several  instances  tlie  constricting 
band  has  merely  passed  from  one  point  on  the  pelvic 
wall  to  another.     When  the  band  has  been  caused  by 


Pig.  4.— Strangulation  of  small  Intestine  by  a  solitary  Band  attached  at 
either  end  to  the  Mesentery. 


some  local  peritonitis  in  connection  with  hernia,  one 
of  its  extremities  may  be  found  attached  to  the 
vicinity  of  the  femoral  or  inguinal  rings,  while  the 
other  end  may  be  fixed  to  the  intestine,  the  mesentery, 


22  Intestinal  Obstruction.        [Chap.  hi. 

or  the  posterior  parietal  peritoneum.  When  the 
band  has  followed  after  typhlitis  (one  of  the  common 
caiises  of  false  ligaments),  both  ends  of  it  may  be 
found  connected  with  the  csecum,  as  is  apparently  the 
case  in  a  specimen  in  the  College  of  Surgeons 
Museum ;  "^  or  it  may  pass  between  the  caecum  and 
the  peritoneum  lining  the  iliac  fossa,  or  attach  itself 
to  the  ileum  or  to  its  mesentery,  or  become  connected 
with  the  lining  of  the  anterior  abdominal  wall.  In 
some  cases,  and  I  think  this  especially  occurs  after 
very  localised  peritonitis  due  to  intestinal  ulcer,  a 
single  band  passes  between  two  neighbouring  coils  of 
intestine.  The  early  stage  of  such  a  band  is  well 
shown  in  Fig.  20.  Perhaps  from  the  same  cause  the 
false  ligament  may  pass  from  the  surface  of  the  bowel 
to  be  attached  to  the  mesentery  of  the  piece  of  intes- 
tine involved,  or  to  the  mesentery  of  another  and 
possibly  distant  segment  of  the  gut. 

Whatever  their  origin,  it  must  be  owned  that  these 
last-mentioned  forms  of  band  are  not  uncommon. 

Among  the  less  usual  attachments  of  these  bands 
may  be  mentioned  the  following :  Between  the 
descending  colon  and  the  mesentery,  f  Between  the 
mesentery  near  the  caecum,  and  the  anterior  surface 
of  the  rectum.  I  Between  the  transverse  colon  and 
the  ciecum  §  (the  band  in  this  case  occurred  in  con- 
nection with  extensive  adhesions  due  to  peritonitis 
after  ulcer  of  the  stomach).  Between  the  omentum 
and  the  mesentery. ||  Between  the  ascending  and  de- 
scending colon.^   Between  the  colon  and  the  ovary.** 

*  No.  1,360a. 

t  St.  Thomas's  Hosp.  Museum,  No.  R  15. 
t  Mr.  A7ard;  Path.  Soc.  Trans.,  1852,  page  302. 
fDr.  Hilton  Fagge  ;   Guy's  Hosp.  Reports,  vol.   xiv.,   18G9, 
page  272. 

II  Dr.  Hilton  Fagge,  loc.  cit. 

11  Seerig.  Rust's  Magazin  fur  Heilkunde,  band  xlvi. 

**  Rokii'.ansky ;  Brit,  and  For.  Med.-Chir.  Keview,  vol.  iii. 


Chap.  III.]        Strangulation  BY  Bands.  23 

In  not  a  few  cases  isolated  cords  of  adhesion  are 
described  as  passing  between  the  sigmoid  fle.xure  and 
distant  parts.  In  this  way  the  flexure  has  been 
connected  -vs-ith  the  ccecum,  with  the  mesentery  near 
the  ca?ciim,  and  with  the  parietal  peritoneum  in  the 
right  iliac  fossa.  Rokitansky  *  reports  a  case  of 
adhesion  between  the  sigmoid  flexure  and  a  coil  of 
small  intestine  in  the  right  hypochondriac  region. 
It  is  well  known  that  the  distended  sigmoid  flexure 
may  reach  the  right  iliac  fossa,  or  even  the  right 
hypochondriac  district,  and  cases  like  the  above  may 
be  explained  on  the  assumption  that  the  flexure 
became  greatly  distended  during  the  time  that  the 
peritonitis  was  active  from  which  the  adhesions  were 
derived.  Such  distension  may  readily  attend  the 
constipation  and  intestinal  paralysis  of  peritoneal 
inflammation. 

Jlethods  of  strangukition. — When  a  portion  of 
the  intestine  is  strangiilated  by  an  isolated  peritoneal 
adhesion  the  gut  will  be  found  to  be  constricted  by 
one  of  two  ways,  1.  It  may  be  strangailated  beneath 
the  band  as  beneath  a  shallow  and  narrow  arch.  2. 
It  may  be  snared  and  constricted  by  a  noose  or  knot 
formed  by  the  false  ligament  itself. 

1.  Strang-ulation  beneath  a  band  can  only  occur 
when  the  band  is  coDiparatively  short,  and  when  it  is 
stretched  along  a  Arm  surface.  From  an  examina- 
tion of  some  fifteen  cases,  where  the  constricting  cord 
is  well  described,  it  would  appear  that  its  average 
length  in  this  form  of  strangulation  is  about  one  and 
a  half  to  two  inches.  The  arch  beneath  which  the 
implicated  bowel  passes  is  variously  described  as 
large  enough  to  admit  one,  two,  or  three  fingers. 
Larger  arches  have  been  formed  permitting  much 
intestine  to  pass  beneath  them,  but  these  great  aper- 
tures ai^e  exceptional  in  acute  cases.  Since  the  cord 
*  Manual  of  Path.  Anatomy  (Syd.  Soc),  vol.  ii.,  1850. 


24  Intestinal  Obstruction.        [Chap.  iii. 

must  be  stretched  along  a  firm  surface  it  happens 
that  this  form  of  stransjulation  is  much  more  com- 
monly  found  about  the  posterior  abdominal  parietes 
than  elsewhere.  It  is  often  met  with  about  the  iliac 
fossse,  especially  that  of  the  right  side,  and  about  the 
brim  of  the  true  pelvis.  When  a  band  passes  be- 
tween two  points  on  the  mesentery  a  coil  of  small 
intestine  may  readily  be  strangulated  beneath  it,  the 
resisting  pai'ts  between  which  the  bowel  is  com- 
pressed being  the  false  ligament  on  the  one  hand,  and 
the  mesentery  on  the  other.  It  will  be  readily 
understood  also  that  a  knuckle  of  the  small  intestine 
may  be  strangulated  with  little  difficulty  when  it 
passes  between  a  band  and  a  solid  viscus  like  the 
uterus.  In  some  few  cases  the  firm  basis  required 
for  this  form  of  obstruction  appears  to  have  been 
provided  by  a  rigid  mass  of  adhesions,  across  which 
the  false  ligament  has  been  stretched. 

2.  Strangulation  by  a  noose  or  knot  requires  a 
lonir  false  liiiament  which  must  lie  loose  and  free  in 
the  abdominal  cavity,  being  attached  only  by  its  two 
ends. 

The  snaring  of  a  coil  of  small  intestine  by  this 
means  must  be  a  matter  of  some  difficulty,  and  must 
be  almost  impossible  in  cases  where  the  bowel  is  per- 
fectly normal.  As  Leichtenstern  has  well  pointed 
out,  the  gvit  in  these  cases  will  usually  be  found  to 
have  been  in  an  abnormal  condition  previous  to  the 
occurrence  of  the  strangulation.     A  knuckle  of  gut 

may  be  rendered  so  adherent 
that  it  could  not  slip  out 
of  the  way  by  peristaltic 
movement  when  it  had  be- 
come  involved  in  the  noose 
or  knot.  It  is  probably  a 
still  more  common  circumstance  for  two  ends  of  a 
loop  of  intestine  to  be  matted  together  by  a  little 


Chap.  III.]       Strangulation  BY  Bands.  25 

mesenterial  peritonitis,  so  that  if  a  noose  should  slip 
over  such  a  loop,  the  constricting  cord  will  find  at  the 


Fig.  6. — Strangulation  by  a  Band.    (Astlty  Cooper.) 
a,  anterior  al)clonilnal  parietes  ;  h,  hand  passing  from  a  lu'vnial  sac  to  surround  the 
intestine  ;  c,  band  returning  to  the  hernial  sac  ;  d,  loop  or  noose  fonned  by 
the  band  ;  e,  intestine  strangulated  by  the  noose  d ;  /,  intestine  strauguhvted 
iu  a  less  degree  by  the  portions  of  the  band  h  and  c. 

base  of  tJie  loop  a  narrowed  neck  around  which  it 
may  take  good  hold.  The  most  common  method 
whereby  a  coil  of  intestine  may  be  snared  is  when  the 
lax   band  forms   a  ring  or  spiral   between   its   fixed 


26 


InTES  TINA  L    ObS  TR  UCTION. 


[Chap.  III. 


points  a  and  h  (Fig.  5).  Through  this  ring  a 
loop  of  the  small  intestine  slips,  or  over  an  abnor- 
mally fixed  coil  of  that  part  of  the  bowel  the  noose 
passes.  For  an  excellent  illustration  of  this  method 
see  Fig.  6.* 

Strangulation  by  the  formation  of  a  knot  is  some- 
what different  from  the  process  of  snaring  just 
described.  The  mechanism  of  this  variety  of  obstruc- 
tion is  thus  described  by  Leich- 
tenstern  :  "  There  are  several 
kinds  of  this  knotting.  The 
most  frequent  is  the  following  : 
The  long  and  loose  ligament  is 
fastened  at  one  end  to  a  loop  of 
the  small  intestine,  and  hangs  in 
the  form  of  a  simple  coil  (Fig.  7). 
If  the  top  of  the  intestinal  loop 
passes  directly  through  the  coil  c, 
a  simple  knot  is  formed  about 
the  piece  of  the  intestine,  as  is 
shown  in  Fig.  8.  It  is  evident  that  the  same  result 
can  be  produced  by  the  coil  being  thrown  over  the 
top  of  and  around  the  intestinal 
loop. 

"  An(;>ther  and  rarc^r  form  of 
knot  is  made  as  follows  :  a  long 
and  perfectly  loose  fcdse  ligament 
forms  a  simple  coil,  like  that  shown 
in  Fig.  5,  between  its  points  of 
attachment  a  and  h.  If  now  one 
leg  of  the  so-formed  primary  noose 
passes  tlirough  it  we  have  a  knot 
like  that  shown  in  Fig.  9,  and  if 
now  the  intestinal  loop  passes  directly  through  c 
(Fig.   9),  it  becomes  firmly  caught  and  strangulated. 

*  From  Sir  Astloy  Cooper's  Treatise  on  Abdominal  Hernia, 
plate  xxvi.,  Figs.  2  and  3. 


Fig.  7. 


Chap.  III.]        Strangulation  by  Bands.  27 

.     .     .     .     A  common  characteristic   of  all  described 

knots  is,  that  when  the  strangulated  intestine  is 
freed  tlie  ligament  can  immediately  be  drawn  out 
straight.""^ 

With  regard  to  the  relative  frequency  of  these 
two  forms  of  strangulation  by  band,  viz.  strangula- 
tion under  the  false  ligament,  and  strangulation  by  a 
noose  or  knot,  my  own  collection  of  cases  gives  the 
proportion  of  the  two  as  about  six 
to  one.  Leichtenstem,  however, 
who  deals  with  a  larger  series  of 
instances,  has  tabulated  fifty-six 
cases  of  strangulation  under  the 
band,  and  twenty-six  by  means  of 
knots  and  snaring. 

With  regard  to  the  amount  of 
intestine  that  may  be  involved  in  a  ■^^^*  ^* 

noose  or  knot,  it  must  be  remembered  that  the 
false  ligament  may,  under  certain  circumstances, 
attain  a  considerable  length.  Thus,  in  Mr.  Obre's 
case  already  alluded  to  (page  6),  the  false  ligament 
was  VI  \  inches  long. 

Into  the  precise  physical  conditions  that  underlie 
the  production  of  strangulation  in  these  and  in 
analogous  forms  of  strangulation  it  is  not  necessary  to 
enter.  Many  theories  exist  upon  the  subject,  and  the 
matter  is  one  rather  of  pure  physics. 

An  excellent  account  of  the  mechanism  of  stran- 
gulation as  applied  to  hernia  has  been  given  by 
Schmidt,!  and  an  able  account  of  the  various  theories 
that  exist  upon  the  question  has  been  furnished  by 
Hueier.J  To  the  works  of  these  authors  the  reader 
is  referred. 

*  Loc.  cit.,  page  528. 

t  Die  Unterleibsbriiche,  Handb.  der  Allgem.  und  Speciel, 
Chirurgie,  Yon  Pitlia  imd  Billroth,  1882,  page  146. 

X  Grundriss  der  Chirurgie,  page  248.     Leipzig,  1883. 


2$  Intestinal  Obstruction.        [Chap.  hi. 

2.  8traiig:ulatioii  by  cords  formed  from 
the  oiiientiim.— These  cords  are  in  all  cases  due  to 
an  adhesion  or  adhesions  formed  between  the  omen- 
tum and  some  other  peritoneal  surface  as  a  conse- 
quence of  peritonitis. 

The  form  and  arrangement  of  these  omental  cords 
show  very  considerable  variety.  Sometimes  the 
lower  border  of  the  omentum,  and  probably  the 
central  part  of  that  border,  becomes  adherent  at 
some  one  sj^ot.  As  a  result  the  inferior  part 
of  the  membrane  is  rolled  up  into  a  round  solid 
band,  and  the  whole  structure  assumes  a  fan-shaped 
outline.  The  base  of  the  fan  is  at  the  transverse 
colon,  while  its  apex  or  narrowed  part  is  represented 
]jy  the  cord-like  extremity  of  the  adherent  epiploon. 
A  case  of  this  character  is  reported  by  Dr.  Hare,  the 
point  of  adhesion  being  at  the  anterior  abdominal 
parictes  below  the  umbilicus."*  In  a  somewhat 
similar  case  described  by  Mr.  Avery  the  extremity  of 
the  omentum  was  twisted  into  a  cord  about  the  size 
of  the  little  finger,  and  attached  to  the  mesentery  in 
the  right  iliac  region,  f 

In  other  cases,  especially  where  one  of  the  lateral 
borders  of  the  epiploon  has  become  adherent,  the 
attached  portion  separates  as  a  cord,  which  becomes 
in  time  dense  and  fibrous.  If  the  omentum  has 
formed  extensive  adhesions,  its  whole  substance  may 
be  changed  into  a  series  of  cords  passing  between  the 
transverse  colon  and  various  other  parts  of  the 
abdominal  cavity.  Such  Avas  the  condition  of  things, 
for  example,  in  a  case  of  Dr.  Fagge's,  the  many  false 
ligaments  that  had  formed  being  attached  to  the 
abdominal    parietes    and    small    intestines   in   many 

*  Piitli.  Soc.  Trans.,  vol.  rii.,  1851,  page  111. 

t  IVjtd.,  vol.  iv.,  page  150.  A  case  of  a  like  character  will  be 
foiind  in  a  paper  by  M.  Berger,  in  Bull,  et  M^m.  de  la  Soc.  de 
Chir.  de  Paris,  tome  vi.,  1880,  page  601. 


Chap.  III.]  Omental  Cords.  29 

places.*  In  any  case  the  omentum  from  which  a 
band  is  dorivcul  is  often  found  much  altered  in  struc- 
ture, having  become  tliin  and  reticulate. 

One  of  the  most  curious  modes  of  forming 
omental  bands  is  met  with  in  a  case  described  by 
Dr.  K.  Fowler.  Here  the  epii)loon  was  divided  into 
two  lateral  cords,  which,  coming  off  from  either  side 
of  the  transverse  colon  passcnl  down  behind  or  among 
the  intestines,  and  were  found  to  be  united  togetlier 
near  the  pelvis.  All  the  patient's  troubles  dated 
from  a  kick  received  upon  tlie  abdomen.  It  is 
probabh;  tliat  in  this  case  a  rent  had  formed  in  tlie 
omentum,  through  which  the  great  bulk  of  the  small 
intestines  had  proti'uded.  The  lateral  jxirts  of  the 
omentum,  i.e.  the  parts  on  either  side  of  the  rent, 
had  then  shrunken  into  cord-like  masses,  which  would 
be  more  or  less  hidden  by  the  bowels.  Dr.  Hilton 
Fagge  has  put  upon  record  an  almost  similar  case  in 
his  monograph  in  the  Guy's  Hospital  Keports. 

When  once  a  portion  of  the  epiploon  has  become 
adherent  the  development  of  the  attached  part  into  a 
ligamentous  cord  is  to  be  explained  by  the  same 
process  that  fashions  a  broad  ribbon-like  adhesion  into 
a  fibrous  thread.  The  segment  of  the  adherent 
omentum  is  continually  being  dragged  upon,  espe- 
cially when  attached  to  a  movable  viscus  ;  it  tends  to 
become  elongated,  while  the  rolling  movements  of  the 
bowels  around  it  help  to  mould  it  into  a  rounded 
cord-like  ligament.     {See  page  G.) 

As  a  rule  the  omental  cords  are  much  coarser  and 
thicker  than  are  the  bands  resulting  from  peritoneal 
adhesions.  Many  are  nearly  as  thick  as  the  finger, 
while  only  a  few  are  described  as  being  very  fine.  In 
the  matter  of  length  they  usually  have  an  advantage 
over  the  simple  band,  as  may  be  expected  from  the 
dimensions  and  relations  of  the  great  omentum. 
*  Guy's  Hosp.  Keports,  loc.  cit. 


30  Intestinal  Obstruction.         [Chap.  iii. 

The  point  of  attachment  of  the  epiploic  band  will 
obviously  depend  upon  the  situation  of  the  peritonitis 
that  renders  it  adherent.  Such  adhesion  may  follow 
after  any  form  of  peritoneal  inflammation  from  which 
a  patient  recovers. 

It  may  be  due  to  a  limited  peritonitis  following 
injury,  as  in  Mr.  Avery's  case  mentioned  above, 
where  the  attachment  was  close  to  a  slit  in  the 
mesentery,  the  result  of  violence.  Pelvic  peritonitis 
may  lead  to  adhesions  in  and  about  the  pelvis,  and 
from  this  cause  the  omentum  has  been  found  con- 
nected with  the  uterus  or  the  ovaries.  In  like 
manner  typhlitis  has  led  to  attachments  to  the  csecum 
and  to  the  peritoneum  in  the  iliac  fossa.  In  other 
and  less  well  defined  instances  the  abnormal  attach- 
ment has  been  found  upon  the  mesentery  and  upon 
the  free  surface  of  the  small  intestine.  Undoubtedly, 
however,  the  most  common  cause  of  omental  adhesion  is 
some  peritonitis  set  up  about  a  hernia,  and  espe- 
cially about  a  femoral  hernia."*  The  frequency  with 
which  omentum  is  found  in  the  latter  form  of  rupture 
is  well  known,  as  is  also  its  disposition  to  become 
adherent  when  once  so  herniated.  Thus  it  happens 
that  the  most  frequent  point  for  the  attachment  of  an 
omental  band  is  in  the  vicinity  of  the  femoral  ring. 
Since  the  omentum  lies  more  to  the  left  than  to  the 
right  side  of  the  abdomen,  omental  hemise  are  more 
common  upon  the  left  side,  and  it  is  therefore 
about  the  hernial  orifices  to  the  left  of  the  middle  line 
that  the  omental  cords  are  more  usually  attached. 

One  of  the  least  common  aspects  of  the  epiploic 
cord  is  shown  in  a  specimen  in  St.  Thomas's  Hospital 
Museum,  in  which  it  will  be  seen  that  the  cord  passes 
merely  from  one  part  of  the  great  omentum  to 
another. 

*  Portions  of  omentum  attached  to  umbilical  herniae  rarely,  if 
ever,  form  actual  cords. 


Chap.  III.]         Meckel^ s  Diverticulum.  31 

While,  as  above  stated,  only  one  peritoneal  false 
ligament  is  usually  found  in  a  given  instance,  the 
omental  adhesions  may  be  met  with  in  the  form  of 
two  or  even  more  cords.  In  the  case  of  epiploic 
adhesions  also  two  cords  may  Ije  found  apparently 
constricting  the  bowel  at  different  points,  and  in  per- 
forming laparotomy  for  the  relief  of  such  obstruction 
the  wrong  band  may  be  divided.  This  circumstance 
happened  to  Mr.  Bryant.  He  had  divided  an  omental 
band  attached  to  the  left  ovary  that  appeared  to  be 
obstructing  the  gut,  but  at  the  autopsy  a  second  cord 
was  found  connected  with  the  uterus,  beneath  which 
was  a  coil  of  ileum  tightly  strangulated.* 

The  modes  of  strangulation  by  omental  cords  are 
identical  with  those  described  in  connection  with 
peritoneal  bands,  although  it  would  appear  that  the 
proportion  of  cases  of  strangulation  by  a  noose  or 
knot  is  greater  in  the  former  than  in  the  latter  class 
of  adhesion.  This  circumstance  is  no  doubt  due  to 
the  greater  average  length,  and  the  greater  mobility 
of  the  omental  false  ligament,  f 

3.  Strangrulation  by  Meckel's  diverticii- 
lum. — The  true  or  Meckel's  diverticulum  is  due  to 
the  persistence  or  incomplete  obliteration  of  the  vitel- 
line duct.  When  met  with  in  its  most  perfect  condi- 
tion it  exists  as  a  tube,  having  a  structure  similar  to 
that  of  the  small  intestine  itself,  that  extends  between 
the  lower  part  of  the  ileum  and  the  umbilicus.  The 
abdominal  end  of  the  tube  opens  into  the  lumen  of 
the  lesser  bowel,  while  the  umbilical  extremity  may 
be  closed,  or  may  open  upon  the  surface  and  permit 
of  the  discharge  of  fsecal  matter.  I  have  myself  met 
with  two  cases  where  such  discharge  took  place. 
Once  in  a  lad,  aged  seventeen,  who  had  been  troubled 
since  birth  with  the  occasional  escape  of  fseces  from  a 

*  St.  Thomas's  Hosp.  Museum,  No.  E,  14. 
t  LoMcet,  vol.  ii.,  1873,  page  773. 


32  Intestinal  Obstruction.        [Chap.  hi. 

sinus  at  the  navel,  and  once  in  a  male  infant  a  few 
weeks  old,  wliere  a  like  condition  existed,  and  upon 
whom  I  successfully  performed  a  plastic  operation  for 
the  closure  of  the  abnormal  passage. 

This  condition,  however,  of  the  diverticle  is  com- 
paratively rare.  Most  commonly  it  exists  as  a  blind 
tube  coming  oft'  from  the  ileum.  The  length  of  this 
tube  is  on  an  average  three  inches,  and  in  the  great 
majority  of  the  examples  the  measurement  extends 
between  one  inch  and  four.  Sometimes  it  exists  only 
as  a  nipple-like  projection.*  On  the  other  hand  cases 
are  recorded  where  the  diverticle,  in  the  form  of  a 
free  tube,  attained  the  length  of  ten  inches.  As  a 
rule  the  abnormal  tube  is  cylindrical  in  shape,  with  a 
conical  extremity.  In  nearly  every  instance  the 
intestinal  end  of  the  diverticulum  is  larger  than  its 
opposite  extremity.  In  no  case,  as  far  as  T  am  aware, 
has  it  been  seen  to  assume  a  polypoid  form,  and 
present  a  comparatively  narrow  attachment.  In 
diameter  its  base  is  usually  less  than  that  of  the  gut 
from  whence  it  arises,  although  sometimes  the  dia- 
meters of  the  two  tubes  may  be  nearly  identical.!  It 
may  retain  the  same  width  throughout,  and  thus 
resemble  a  glove  finger.  Much  more  frequently,  how- 
ever, its  free  extremity  is  considerably  narrower 
than  its  base. 

In  structure  the  diverticulum  is  composed  of  all 
the  layers  of  normal  small  intestine.  Its  mucous 
membrane  is  smooth,  and  possesses  Lieberkiihn's 
follicles.  It  often  presents  also  a  Peyer's  patch 
(Cazin).  The  muscular  coat  is  sometimes  deficient  at 
the  apex  of  the  diverticle,  and  at  this  spot,  therefore, 
hernial  protiusions  of  the  mucous  membrane  under 
the    serous    coat    are    not    infrequently    met    with. 

*  Guy's  Hosp.  Museum,  No.  1,819  (45). 

t  For  an  instance  of  a  very  wide  diverticulum  sec  specimen 
No.  1.819  (50),  in  Guy's  Hosp.  Museum. 


Chap.  III.]  Meckel's  Djverticulu.u.  33 

When  this  occurs  the  extremity  of  the  abnormal  tube 
presents  an  ampulla  of  globular  shape,  and  the  process 
is  said  to  be  "  clubbed."  In  one  dried  j)roparation  in 
the  London  Hospital  Museum  the  ampulla  at  the  end 
of  a  diverticulum  has  so  peculiar  an  outline  that  the 
whole  process,  which  is  of  no  great  length,  looks 
hammer-shaped.  The  clubbed  extremity  of  the 
diverticulum,  when  it  exists,  takes  an  important  part 
in  the  production  of  strangulation  by  knotting.  In 
cases  where  the  diverticulum  appears  as  a  compara- 
tively immense  pouch  there  is  little  doubt  but  that 
the  process  has  been  exposed  to  a  considerable  degree  of 
distension.  Cazin  figures  a  case  where  a  species  of  valve 
or  diaphragm  existed  between  the  diverticulum  and  the 
intestine."^     Meckel  alludes  to  a  similar  arrangement. 

The  diverticulum  is  always  single,  and  arises  from 
the  ileum  from  one  to  three  feet  above  the  ileo-ca3cal 
valve.  It  is  extremely  rare  for  the  process  to  take 
origin  beyond  these  limits.  Cazin,  however,  alludes 
to  a  case  where  it  is  said  to  have  arisen  from  the 
ileum,  twenty  lines  from  the  cascum.  In  a  specimen 
in  Guy's  Hospital  Museum  f  the  process  is  described  as 
springing  from  the  middle  of  the  ileum. 

The  process  may  come  off  at  an  acute  angle  with 
the  long  axis  of  the  bowel,  but  more  usually  the 
angle  formed  is  a  right  angle. 

It  is  sometimes  provided  with  a  scanty  mesentery, 
as  is  shown  in  a  drawing  by  Sandifort. 

The  end  of  the  diverticulum  is,  in  the  majority  of 
cases,  free.  Very  often,  however,  it  is  continued  in 
the  form  of  a  solid  cord.  This  cord  should  be 
attached  to  the  umbilicus  or  to  the  abdominal  parietes 
immediately  below   that  cicatrix.  |     This  attachment 

*  Etude  sur  les  Diverticules  de  I'lntestin.     Paris,  1862. 
t  No.  1,819  (50). 

+  St.  Bart.'s  Hosp.  Museum,  No.  2,168,  and  many  other  speci- 
mens. 

D— 12 


34  Intestinal  Obstruction.        [Chap.  hi. 

is,  indeed,  very  frequently  met  with.  Often  tlie  cord 
is  pervious  for  a  little  way,  and  presents  a  minute 
canal  into  which  a  bristle  may  be  inserted.  This 
diverticular  ligament  may  break  from  its  attachment 
to  the  parietes  and  may  float  free  within  the  ab- 
dominal cavity.  Under  such  circumstances,  however, 
it  is  much  more  usual  for  it  to  acquire  fresh  adhesions 
to  some  point  of  the  peritoneal  surface. 

These  secondary  adhesions  of  a  free  diverticulum, 
or  of  a  diverticular  cord  at  the  extremity  of  one  of 
the  processes,  are  of  considerable  importance  in  the 
etiology  of  strangulation  of  the  intestine.  It  is  by 
the  diverticulum  that  has  acquired  a  fresh  point  of 
attachment  that  constriction  of  the  bowel  is  most 
often  effected.  It  is,  in  the  great  majority  of  cases, 
to  the  mesentery  that  the  tube  or  the  cord  continued 
from  it  is  adherent."^  This  adhesion  may  be  found 
on  a  portion  of  the  mesentery  above  the  origin  of  the 
diverticulum,  but  somewhat  more  frequently  it  is  on 
the  mesentery  of  tlie  ileum  between  the  point  of  origin 
of  the  process  and  the  caecum. 

The  loop  formed  by  such  an  adhesion  presents  the 
greatest  possible  variety.  When  the  diverticulum  is 
very  small  and  short,  the  ring  that  it  forms  is  quite 
insignificant,  and  incapable  of  engaging  more  than  a 
slight  portion  of  the  intestine. f     When,  however,  the 

*  In  twenty-three  cases  collected  by  Cazin  the  points  of 
attachment  of  the  diverticulum  were  as  follows  • 


To  colon         1 

To  mesentery  ...         ...  10 

23 


Near  umbilicus         ...         ...  3 

Near  inguinal  ring   ...         ...  1 

To  small  gut G 

To  caecum      ...         ...         ...  2 

In  nineteen  additional  cases  collected  by  myself  the  attach 
ments  were  as  follows  : 

Near  umbilicus         ...         ...  7 

To  femoral  rin^        ...         ...  1 


To  small  gut 3 

To  caecum      1 

t  Guy's  Hosp.  Museum,  No.  1,819  (36) 


To  mesentery  ...         ...     7 

19 


Chap.  III.]  Meckel's  Diverticulum.  35 

process  is  long,  and  especially  when  it  ends  in  an 
elongated  cord  or  ligament,  a  loop  of  considerable  size 
may  be  formed,  and  nooses  and  knots  may  be  developed 
capable  of  snaring  many  coils  of  the  bowel.* 

In  other  cases  the  diverticle  or  diverticular  cord 
is  attached  to  some  other  part  of  the  small  intestine 
or  to  the  omentum,  or  to  some  point  on  the  ab- 
dominal parietes  other  than  the  immediate  vicinity 
of  the  umbilicus.  In  many  instances  it  is  evident 
that  the  site  of  the  adhesion  has  been  influenced  by 
some  definite  form  of  localised  peritonitis.  Thus  the 
extremity  of  the  diverticulum  has  been  found 
attached  to  the  pelvic  viscera  or  pelvic  parietes  after 
peritoneal  inflammation  in  that  region,  to  the  caecum 
or  peritoneum  about  the  right  iliac  fossa  after  typh- 
litis, and  to  the  vicinity  of  the  femoral  and  inguinal 
canals  after  hernia.  In  some  specimens  the  peri- 
tonitis causing  the  adhesion  has  evidently  been  set 
up  by  mesenteric  gland  inflammation. 

In  another  series  of  cases  the  diverticulum  does 
not  exist  as  such,  but  is  replaced  in  its  entire  length 
by  a  fibrous  cord  identical  in  aspect  with  the  band 
so  often  seen  attached  to  the  apex  of  the  tubular  pro- 
cess. These  cords  may  be  found  to  extend  between 
the  parietes  in  the  vicinity  of  the  umbilicus  and 
that  part  of  the  ileum  from  which  the  more  familiar 
diverticle  takes  origin.  They  may  be  considered  to 
represent  an  entirely  obliterated  diverticulum,  or  may 
be  the  remains  of  persisting  omphalo-mesenteric 
vessels.!  A  case  belonging  to  the  latter  category 
has  been  placed  on  record  by  I)r.  Mahomed.  In  this 
instance  a  fibrous  band  extended  from  tbe  middle  of 
the  anterior  abdominal  wall  (midway  between  the  pubes 
and    the    umbilicus)   to    the    right    iliac    fossa.      The 

*Patli.  Soc.  Traus.,  vol.  xxi.,  page  185. 

^  See  an  exhaustive  paper  on  Persistent  Omphalo-Mes.  Ra 
mains,  by  Dr.  Fitz ;  Amer.  J.  of  Med.  Sc,  July,  1884. 


36  Intestinal  Obstruction.        [Chap.  hi. 

deeper  extremity  of  the  cord  had  snared  in  a  noose 
a  large  portion  of  ileum.  It  then  attached  itself  to 
the  mesentery,  some  three  feet  from  the  ileo-csecal 
valve,  and  was  found  to  be  continuous  with  a  branch 
of  the  ileo-colic  artery.  The  more  superficial  ex- 
tremity of  the  band  divided,  one  part  ascending  to 
the  navel  with  the  obliterated  hypogastric  artery,  the 
other  descending  to  form  the  left  superior  vesical 
artery.     The  cord  was  quite  impervious  to  injection.* 

These  diverticular  ligaments  may  break  loose  from 
their  connections  at  the  umbilicus,  and  may,  like  the 
tubular  processes,  either  remain  free  in  the  abdominal 
cavity,  or  form  secondary  adhesions  at  almost  any  spot. 

To  still  further  complicate  this  matter,  the  cord 
may  retain  its  attachment  to  the  anterior  abdominal 
wall,  and  separate  from  its  connection  with  the  intestine. 
It  may  then  either  form  no  other  attachment,  or  may 
adhere  to  a  point  somewhere  within  the  abdomen,  f 

Finally,  a  cord  may  be  found  to  stretch  from  the 
root  of  the  mesentery  to  be  attached  to  the  margin 
of  the  ileum  (close  to  its  mesentery)  opposite  the 
spot  from  which  the  diverticle  most  commonly  arises. 
Leichtenstem  believes  that  such  bands  rejiresent  that 
part  of  tho  omphalo-mesenteric  vessels  that  extends 
between  the  bowel  and  the  main  blood-vessels  at  the 
root  of  the  mesentery.  He  gives  a  figure  to  show  the 
continuation  of  this  band  with  an  ordinary  diverticu- 
lum which  is  attached  by  a  cord  to  the  umbilicus.  A 
false  ligament  described  by  Dr.  David  King  may 
possibly  have  been  of  this  nature.  This  band,  which 
was  an  eighth  of  an  inch  in  diameter,  passed  from 
the  upper  part  of  the  root  of  the  mesentery  to  a  point 
on  the  small  intestine.  Beneath  it  a  piece  of  bowel 
liad  become  strangulated,  t 

*  Path.  Soc.  Trans.,  vol.  xxvi.,  page  47. 

t  Spangenberg,  Arch.  f.  Phys.  v.,  Sleckel,  b.  v.,  s.  87. 

+  St.  Bart.'s  Hosp.  Reports,  vol.  xvii.,  1881,  page  277. 


Chap.  Ill]         Meckei^s  Diverticulum.  37 

Tliere  can  be  little  doubt  but  that  these  strangely 
attached  diverticular  ligaments  have  often  been 
mistaken  for  isolated  peritoneal  adhesions ;  and,  in 
any  case,  where  a  "  solitary  band  "  exists  without  a 
trace  of  ancient  peritonitis,  there  are  some  prima- 
facie  grounds  for  suspecting  the  cord  to  be  of  con- 
genital origin. 

The  diverticulum,  as  already  stated,  is  always 
single.  The  same  remark  applies,  with  but  few 
exceptions,  to  the  diverticular  ligaments.  In  a  few 
instances  the  cord  seems  to  have  divided,  so  that  an 
appearance  as  of  two  bands  has  been  produced.  Such 
is  apparently  the  case  in  a  specimen  in  one  of  the 
museums,*  in  which  one  ligament  encircles  a  loop  of 
bowel  and  strangulates  it,  while  the  other  goes  to  be 
attached  to  the  vicinity  of  the  femoral  ring. 

It  may  be  here  mentioned  that  a  free  true  diver- 
ticulum has  in  several  instances  been  found  in  an 
external  hernia.  One  of  the  earliest  cases  of  this 
kind  is  described  by  Littre.  f  In  this  case  a  diverticle 
four  inches  in  length  was  found  in  a  scrotal  hernia 
in  a  man  aged  48.  It  is  evident  that  Littre  was 
unaware  of  the  nature  of  the  intestinal  pouch.  | 
Cazin  gives  a  drawing  to  show  a  Meckel's  diverticu- 
lum in  a  scrotal  hernia  from  a  case  dissected  by 
himself  § 

Methods  of  'producing  strangulation. — 1.  A  coil  of 
small  intestine  may  be  strangulated  beneath  an 
adherent  diverticulum  precisely  in  the  same  manner 
as  it  would  be  when  beneath  a  peritoneal   adhesion. 

*  St.  Bart.'s  Hosp.  Museum,  No.  2,173. 

t  Mem.  de  I'Acad.  dee  Sciences,  1700,  page  300,  ''Observat. 
sur  una  nouvelle  Espece  de  Hernie. " 

+  A  full  account  of  the  relation  of  the  diverticulum  to  hernia 
will  be  found  in  "  Du  Pincement  Herniare  de  I'lntestin,"  by  M. 
Loviot.     Paris,  1879. 

§  Loc.  cit.,  Fig.  14.  See  also  case  by  Busch,  Central,  fiir 
Chirurg.,  1884,  No.  23,  page  69. 


38  Intestinal  Obstruction.        [Chap.  in. 

An  illustration  of  this  mode  of  constricting  the  bowel 
is  shown  in  Fig.  10,  from  a  case  reported  by  M. 
Rayer.^  It  is  scarcely  possible  to  conceive  that  this 
method  of  producing  obstruction  can  occur  when  the 
diverticulum  simply  extends  between  the  ileum  and 
the     anterior     abdominal     wall. 

fYet    several   cases    are   recorded 
^     where  the  diverticulum  ha,d  these 
attachments,     and   where     it    is 
vaguely  stated  that  beneath  the 
process  some  bowel  was  strangu- 
lated.    In  the  absence  of  clearer 
evidence    these    cases    must    be 
accepted  with  some  little  doubt. 
'^'^W'an  adt'^DWez-      Certainly,  in  nearly  all   reported 
tide.    (Kayer.)  instances  of  Strangulation  under 

"'"end'oTgiuf^^J'ionrrf';  ^  diverticulum,  the  process  has 
stonguiatud'ioop.^'  ^^"^  been  adherent  to  a  point  other 
than  the  vicinity  of  the  um- 
bilicus. When  the  adhesion  is  to  the  mesentery, 
as  is  so  frequently  the  case,  it  will  be  readily  under- 
stood that  beneath  the  arcade  so  formed  a  loop  of 
intestine  may  be  with  great  ease  engaged  and  com- 
pressed. This  condition  of  the  parts  is  often  met 
with. 

2.  A  diverticular  ligament,  whetlier  attached  to 
the  extremity  of  a  pouch-like  process,  or  (in  the 
absence  of  such  process)  connected  directly  with  the 
gut,  may  form  precisely  the  same  kinds  of  noose  and 
knot  as  are  formed  by  isolated  adhesions.  The  length 
and  looseness  of  the  congenital  ligament  render  it  well 
able  to  snare  the  bowel,  provided  that  the  position 
and  circumstances  of  the  bowel  render  it  capable  of 
being  snared. 

The  strangulation  of  a  loop    of   intestine   by  the 
simple  noose  or  spiral,   depicted  on  page  24,  would 
*  Archiv.  Gen ,  do  Med. ,  tome  v. ,  page  68. 


Chap.  III.] 


Meckel^ s  Diver  tic ul  um. 


39 


appear  to  be  fairly  common  in  the  case  of  diverticular 
cords.  The  numerous  specimens  found  in  museums, 
where  these  cords  are  seen  to  have  made  one  and  a 
half   or    two   turns   round   the   involved   bowel,    are 


Fig.  11.— Strangulation  by  Meckel's  Diverticulum. 

a,  point  of  origin  of  diverticle.  The  distal  end  is  attached  to  the  mesentery.  The 

loop  involved  measured  12  inches. 

probably  of  this  character.  An  example  of  this 
variety  of  strangulation  in  its  simplest  form  is 
depicted  in  Fig.  11."^  In  some  instances  the  band 
will  be  seen  to  have  passed  twice  round  the  bowel  at 
the  point  of  constriction.!      Iii  other  specimens  one 

*  Lond.  Hosp.  Museum,  No.  Ag.  2. 

t  For  specimens  see  St.  Bart.'s  Hosp.  Museum,  No.  2,172,  and 
University  Coll.  Museum,  No.  1,167. 


40  Intestinal  Csstruction.        [Chap.  hi. 

and  a  half  turns  are  made.  A  reference  to  the 
drawing  taken  from  Sir  Astley  Cooper's  work 
(Fig.  G),  will  show  the  manner  whereby  the  gut  is 
snared  in  these  nooses,  and  will  also  explain  how  in 
constriction  by  a  simple  spiral  an  appearance  is  pro- 
duced as  of  a  cord  passing  one  and  a  half  or  two 
times  round  the  bowel.  Very  often  the  strangulation 
by  a  noose  is  a  little  more  complicated.  In  a  case 
reported  by  Dr.  Bristowe,  *  the  spiral,  although 
simple  in  itself,  was  yet  so  arranged  around  the 
intestinal  coils  as  to  compress  them  in  four  different 
places.  In  a  case  recorded  by  Moscati,t  the  diver- 
ticular band  formed  a  definite  figure  of  8  loop  in 
which  the  intestinal  coils  were  so  involved  as  to  be 
constricted  in  three  places.  What  mechanism  is 
involved  in  producing  these  extraordinary  forms  of 
obstruction,  and  what  movements  of  the  bowel  and 
what  arrangement  of  the  band  are  requisite,  must  be 
at  present  a  matter  of  pure  speculation. 

The  relative  frequency  of  the  two  forms  of 
strangulation  already  described,  viz.  under  the  band 
and  by  the  noose  or  knot,  is  represented  by  Leichten- 
stern,  by  the  figures  40  and  14  in  a  total  of  54  cases. 
These  figures  are  a  little  difficult  to  understand,  if 
taken  in  connection  with  the  experience  gained  by  an 
examination  of  all  the  specimens  to  be  found  in  the 
various  museums  of  London.  These  specimens  cer- 
tainly appear  to  show  that  strangulation  by  snaring 
is  by  no  means  uncommon,  and  that  this  form  of  ob- 
struction does  not  bear  to  the  constrictions  under  the 
band  so  wide  a  proportion  as  1  to  4.  If  one  could 
judge  from  an  inspection  of  museum  specimens  only,  it 
would  seem  that  stranijulation  under  the  diverticular 
band  is  only  about  twice  as  frequent  as  is  the  more 
comj)licated    method    of    obstruction.     According    to 

*  Path.  Soc.  Trans.,  vol.  xxi.,  page  185. 

t  Mem.  de  I'Acad.  de  Chiiurg.,  tome  iii.,  page  468. 


Chap.  III.]        Meckel's  Diverticulum.  41 

Leichtens tern's  figures,  strangulation  by  the  noose  is 
relatively  more  frequent  in  the  case  of  the  peritoneal 
adhesion  than  it  is  in  the  case  of  the  congenital  band. 
This  fact  also  is  in  direct  opposition  to  the  conclusions 
derived  from  the  museum  sj)ecimens,  and  I  am  strongly 
inclined  to  believe  that  obstruction  by  snaring  is 
relatively  more  frequent  when  the  diverticulum  is 
concerned  than  when  the  trouble  is  brought  about  by 
the  false  ligament.  This  latter  conclusion  is  one  that 
would  be  anticipated  if  the  gi*eater  average  length  and 
the  greater  mobility  of  the  diverticular  ligament  be 
borne  in  mind. 

3.  Strangulation  hy  knots  formed  hy  a  free  diver- 
ticulum.— These  remarkable  knots  and  the  methods 
of  their  formation  have  been  very  exhaustively  studied 
by  M.  Parise.*  To  produce  these  knots  it  is  neces- 
sary that  the  diverticulum  should  be  of  good  length, 
should  be  quite  free  (save  only  for  its  intestinal 
attachment),  and  should  possess  an  ampulla  at  its 
extremity.  The  importance  of  the  ampulla  is  para- 
mount, and  French  writers  are  in  the  habit  of  speaking 
of  it  as  la  clef  de  Vetranglement.  Three  varieties 
of  knot  may  be  described  : 

a.  The  diverticle  forms  a  ring  into  which  its  own 
free  end  projects  (Fig.  12).  A  loop  of  intestine 
entering  the  centre  of  that  ring  will 
push  the  clubbed  end  of  the  process 
before  it  and  so  tie  the  knot  by  which 
the  coil  becomes  obstructed. 

h.  The  diverticulum  surrounds  the 
pedicle  of  an  intestinal  loop  in  such  a 
way  as  to  encii'cle  it  with  a  simple  knot. 
The  mode  of  formation  of  the  noose  is  Fig.  12. 

shown   in   Fig.    13,       Of   this  variety 
M.    E,egnault    gave    many    years    ago    an   excellent 
example.     The  diverticle  was  in  this  case  six  inches  in 
*Bull.  cle  I'Acad.  de  Med.,  tome  xvi.,  page  373k 


42 


Intestinal  Obstruction.        [Chap.  in. 


length,  and   by  its   means   one   and    a   half   feet   of 
intestine  were  strangulated. 

c.  In  this  form  two  loops  of  the  bowel  are  involved 
(Fig.  14),  one  above,  a,  and  the  other  below,  6, 
the  origin  of  the  diverticulum,  d.     One  of  the  loops 


Fig.  13.— One  mode  of  Strangulation  by  the  Diverticulum.     (Kegnault- 

B^clard.) 

fl,  origin  of  diverticle  ;  6,  its  clubbed  extremity. 

enters  the  knot  by  a  preliminary  rotation  ("  anse 
rotatoire "),  e,  the  other,  is  noosed  by  the  diver- 
ticulum, as  in  the  simple  knot  ("  anse  nodale ")  c. 
There  appears  to  have  been  only  one  case  recorded  of 
this  species  of  knot.*  The  commonest  form  of  knot 
is  undoubtedly  the  second  of  the  three  now  given. 

Diverticula  and  diverticular  ligaments  may  lead  to 
other  forms  of  obstruction  which   do   not,   however, 

*  "  Observat.  d'une  nouvelle  Forme  d'Etrang.  dite  par  Noeud 
iutestinab"  by  Dr.  M.  Levy ;  Gazette  Medicale,  1845,  page  129. 


Chap.  III.]         Meckel's  Diverticulum.  43 

come  under  the  present  category.  These  forms  may 
be  enumerated  here  for  the  sake  of  completeness,  and 
will  be  dealt  with  in  detail  in  subsequent  paragraphs. 
4.  Strangulation  over  a  divei'ticular  hand. — In  this 
form  a  loop  of  intestine  is  thrown  over  a  tightly  drawn 
diverticular  band  as  a  shawl  is 
thrown  over  the  arm.  Under 
certain  conditions,  which  need 
not  be  here  detailed,  an  obstruc- 
tion follows  in  the  bowel  so 
displaced.  The  occlusion  is  some- 
what similar  to  that  that  would 
take  place  in  a  coil  of  thin  india- 
rubber  tubing,  if  thrown  across  a  a 
tense  wire   cord    and  allowed  to     Fig.  14.  —  strangi^lation 

■ITT,  by  tlie  Diverticulum 

become  dependent.  ^  \,y  a  double  Kuot. 

6.  Strangulation  hy  kinking. 
— If,  under  certain  circumstances,  much  traction  be 
brought  to  bear  on  a  diverticular  ligament,  the  gut, 
without  undergoing  any  structural  alteration,  may 
l)ecome  so  acutely  bent  at  the  point  of  origin  of  the 
abnormal  band  or  process  as  to  be  occluded.  It  has 
been  shown  also  that  a  free  diverticulum,  when  of  good 
size,  and  coming  off  at  about  a  right  angle  with  the 
bowel,  may  cause  such  bending  of  the  bowel,  when 
the  pouch  is  much  distended,  as  to  cause  obstruc- 
tion. 

6.  Strangulation  hy  the  effects  of  traction. — In 
these  cases  the  bowel  at  the  point  of  origin  of  the 
diverticle  undergoes  certain  gross  structural  changes 
which  may,  in  time,  bring  about  intestinal  obstruction. 
There  is  evidence  to  show  that  these  changes  result 
from  long  continued  traction  upon  the  bowel,  brought 
about  by  means  of  an  adherent  diverticular  process. 

It  may  be  noted  that  foreign  bodies  that  have  been 
swallowed,  and  intestinal  concretions  of  various  kinds, 
may  lodge  within  the  pouch-like  diverticula,  and  excite 


44  Intestinal  Obstruction.        [Chap,  in, 

in  them  ai\  inflammation  of  like  character  and  like 
tendencies  to  that  set  up  in  the  vermiform  appendix 
by  identical  substances. 

One  effect  of  the  true  diverticulum  in  producing 
intestinal  obstruction  is  illustrated  by  a  specimen  in 
Guy's  Hospital  Museum,  that  is,  so  far  as  I  am 
aware,  unique.  In  this  case  a  short  finger-like 
diverticulum  had  become  inverted,  had  projected  into 
the  lumen  of  the  intestine  and  had  led  to  the  forma- 
tion of  an  intussusception."^ 

In  order  of  frequency  the  various  methods  of 
producing  obstruction  by  the  diverticulum  may  bo 
arranged  as  follows  :  (1)  By  strangulation  under  the 
diverticulum';  (2)  by  loops  or  nooses;  (3)  by  diverticular 
knots.  Ijeiclitenstern's  figures  for  these  three  varieties 
are  40.  1 4,  and  1 2.  Strangulation  over  a  band  or  by 
kinking,  and  obstruction  from  the  effects  of  long- 
continued  traction,  are  all  comparatively  rare. 

False  diverticula. — It  will  be  convenient  to 
take  note  here  of  certain  acquired  diverticula  that 
may.  under  some  circumstances,  be  possibly  confused 
with  the  congenital  variety. 

In  all  essential  points,  in  structure,  in  position, 
and  in  nimiber,  these  diverticula  differ  entirely  from 
Meckel's  process. 

They  are  simply  hernial  protrusions  of  the  mucous 
membrane  of  the  bowel  through  the  muscular  coat, 
and  hence  the  common  name  "  distension  diverticula." 
In  structure  they  are  composed  simply  of  mucous 
membrane  and  peritoneum.  They  present  in  their 
walls  no  muscular  fibres.  The  lining  mucous  mem- 
brane in  the  smaller  pouches  is  quite  normal,  but  in 
the  larger  diverticula  that  membrane  becomes  atro- 
phied and  its  glandular  structures  tend  to  disappear. 
They  may  be  met  with  in  any  part  of  the  bowel,  but 
are  somewhat  more  often  found  in  the  large  than  in 
*  Guy's  Hosp.  Museum,  No.  1,819  (45). 


Chap.  III.]  False  Dij'erticula.  45 

the  small  intestine.  They  have  been  seen  in  the 
duodenum,  are  comparatively  common  in  the  jejunum, 
and  are  encountered  with  still  greater  frequency  in 
the  ileum.  They  may  appear  in  any  part  of  the 
colon,  but  are  most  common  in  the  sigmoid  flexure 
and  rectum. 

In  the  matter  of  numbers  they  show  the  greatest 
variety,  and  are  far  more  frequently  multiple  than 
smgle.  The  chief  examples  of  midtiple  diverticula 
are  met  with  in  the  large  intestine.  Alibert  couuted 
two  hundred  in  one  colon.  In  the  museum  of  St. 
Thomas's  Hospital  is  a  sigmoid  flexure,  the  whole 
surface  of  which  is  studded  with  a  multitude  of  little 
hernial  pouches,  varying  in  size  from  a  pin's  head  to  a 
marble.  Pig.  15,  from  Sir  Astley  Cooper's  work  on 
hernia,  shows  a  jejunum,  along  the  mesenteric  border 
of  which  distension  diverticula 
are  crowded  almost  as  closely  as 
they  can  lie. 

The  chief  examples  of  single 
pouches  are  met  with  in  the 
lesser  bowel.  Thus  Dr.  Bristowe 
has  reported  an  instance  of  a 
single  diverticulum  no  larger  than  j^io.  15^ 

a  horse-bean,  situated  in  the  ileum 

just  above  the  ileo-caecal  valve."^  In  other  cases  only 
two  pouches  were  found  in  the  small  intestine,  as  in 
an  instance  noted  by  Dr.  Hilton  Fagge,  where  the 
abnormal  sacs  were  both  in  the  jejunum. f 

In  size,  the  false  diverticulum  may  also  show  any 
dimensions  between  that  of  a  pin's  head  and  that  of  a 
large  apple.  In  sha]>e  they  are  usually  globular, 
especially  when  small.  |  When  of  larger  size  they 
may  become  lobulated,  as  is  the  case  with  one  of  the 

*Path.  Soc  Trans.,  vol.  vi.,  page  191. 

t  Ibid. ,  vol.  xxvii. ,  page  147. 

j  Guy's  Hosp.  Museum,  No.  1,819  (69). 


46  Intestinal  Obstruction.        [Chap.  in. 


Fig.  16.— False  Diverticula. 


Chap.  III.]  False  Diverticula,  47 

diverticula  shown  in  Fig.  16.*  It  is  extremely  rare 
for  them  to  assume  the  conical  shape  or  finger-]  ike 
outline  so  commonly  met  with  in  Meckel's  diverticula. 
They  are  usually  narrower  at  the  attached  extremity 
than  at  the  fundus,  and  are  apt,  when  of  good  size,  to 
assume  a  polypoid  outline. 

As  regards  the  relation  of  these  hernial  pouches  to 
the  intestinal  wall,  it  will  be  found  that  in  the  lesser 
bowel  they  invariably  appear  along  the  mesenteric 
border  of  the  gut,  and  force  their  way,  as  they  en- 
large, between  the  two  layers  of  the  mesentery.  In 
the  colon  they  are  usually  met  with  on  those  parts  of 
the  intestine  to  which  the  appendices  epiploicae  are 
attached,  and  into  the  substance  of  these  appendages 
the  pouch  will,  as  a  rule,  be  found  to  have  projected. 
This  relation  of  the  diverticulum  to  the  appendices 
was  admirably  shown  in  the  case  reported  by  Dr. 
Bristowe. 

It  is  probable  that  all  these  pouches  are  due  to 
distension,  and  may  be  regarded  as  hernise  of  the 
mucous  membrane  through  the  muscular  coat.  They 
occur,  with  but  few  exceptions,  in  old  people  ;  and 
those  of  the  colon  are  usually  associated  with  a  his- 
tory of  chronic  constipation.  In  the  small  intestine, 
also,  the  diverticula  are  as  a  rule  attended  with  con- 
ditions bringing  about  great  distension  of  the  bowel. 
In  Sir  Astley  Cooper's  case  the  pouches  were  in  the 
jejunum,  while  in  the  ileum  was  an  obstruction  of 
slio-ht  character,  that  had  no  doiibt  encouragfed  a  Ions:- 
continued  distension  of  the  intestine.  In  several 
other  instances  the  protrusions  were  met  with  in 
patients  who  had  sufiered  from  hernia,  the  diverticula 
being  situated  in  a  part  of  the  bowel  above  that  in- 
volved in  the  rupture.  Of  the  exact  pathology  of 
these  little  pouches  it  must  be  confessed  that  very 
little  is  known.  If  they  are  due  to  distension  it  is 
*  Coll.  of  Surgeons  Museum,  No.  1,177. 


48  Intestinal  Obstruction.        [Chap.  hi. 

difficult  to  understand  why  they  are  not  met  with 
more  frequently  in  cases  of  acute  and  chronic  intes- 
tinal obstruction.  In  such  cases  they  are  indeed, 
with  the  exceptions  above  named,  practically  un- 
known. The  formation  of  one  diverticulum  as  a 
result  of  localised  distension  is  not  difficult  to  under- 
stand, but  in  those  cases  in  which  several  continuous 
feet  of  the  bowel  present  these  pouches,  conditions  are 
involved  that  have  certainly  not  yet  been  interpreted. 
Over  and  over  again  the  gut  is  found  at  an  autopsy 
enormously  distended,  sometimes  in  its  entire  length, 
sometimes  in  a  limited  segment,  and  yet  no  diver- 
ticula are  present,  although  the  distension  may  have 
been  so  extreme  as  to  rupture  the  serous  coat. 

I  have  only  been  able  to  find  one  reported  case  of 
a  false  diverticulum  in  a  child.  The  case  ^  reported 
by  Dr.  Piatt, "^  and  presents  some  extraordinary 
features.  The  patient  was  a  little  girl  aged  nine. 
The  autopsy  showed  that  she  had  a  stricture  of  the 
small  intestine,  due  probably  to  the  contraction  of  a 
tubercular  ulcer.  This  stricture  had  become  plugged 
by  a  hard  faecal  mass,  and  the  child  presented  the 
symptoms  of  acute  obstruction.  On  examination  by 
the  rectum  a  soft  elastic  tumour  was  felt  pressing 
upon  the  anterior  wall  of  the  bowel.  At  its  lower 
extremity  was  an  orifice  like  an  os  uteri,  into  which 
the  finger  could  be  introduced.  This  was  supposed  to 
be  the  orifice  of  an  invaginated  piece  of  bowel,  and 
the  case  was  presumed  to  be  one  of  intussusception. 
The  autopsy  showed  that  there  was  no  invagination 
of  any  part  of  the  gut,  and  the  tumour  proved  to  be 
a  false  diverticulum  of  the  rectum,  into  the  orifice  of 
which  the  finger  had  been  introdiiced  in  the  rectal 
examination. 

In  no  case,  I  believe,  has  the  distension  diverticu- 
lum caused  an  intestinal  obstruction.  A  specimen  in 
*  Lancet,  vol.  i.,  1873,  page  42. 


Chap.  III.]  False  Diverticula.  49 

the  Guy's  Hospital  Museum*  shows  an  intussuscep- 
tion in  the  immediate  vicinity  of  such  a  pouch,  and 
from  the  condition  of  the  parts  there  is  every  reason 
to  believe  that  the  diverticulum  was  antecedent  to 
the  obstruction.  The  connection,  however,  between 
the  two  might  have  been  purely  accidental. 

These  pouches,  and  especially  those  of  the  colon, 
are  apt  to  lodge  little  faecal  masses  and  foreign 
matters  of  various  kinds.  Inflammation  of  the  pouch 
may  be  induced  by  such  lodgment,  and  peritonitis 
from  perforation  result,  just  as  occurs  in  the  appendix 
vermiformis.  Notice  has  already  been  drawn  to  the 
fact  that  the  colic  diverticula  are  apt  to  project  into 
appendices  epiploicae ;  and  it  is  quite  probable  that  in 
those  cases  where  such  an  appendix  has  caused  an 
isolated  adhesion  a  pouch  might  have  formed  in  the 
appendage,  have  lodged  a  foreign  substance  of  some 
kind,  and  have  been,  in  consequence,  the  seat  of  a  limited 
peritonitis.  Thus,  Mr.  Hulke  records  a  case  where  an 
epiploic  appendage  was  adherent  to  the  pelvic  perito- 
neum near  the  right  sciatic  notch.  Beneath  the 
arcade  so  formed  a  loop  of  bowel  had  been  strangu- 
lated. The  appendix  was  on  the  sigmoid  flexure, 
which  extended  in  an  angular  loop  across  the  pelvis. f 
In  a  specimen  in  the  College  of  Surgeons  Museum  it 
will  be  seen  that  an  appendix  has  become  adherent  to 
the  omentum  in  such  a  way  as  to  cause  stenosis  of 
the  part  of  the  colon  from  which  it  arose.  In  this 
case  tlie  comparatively  large  size  of  the  involved 
appendix  is  conspicuous.  | 

I  have  found  two  cases  on  record  where  a  false 
diverticulum  in  the  sigmoid  flexure  communicated 
witli  the  interior  of  the  bladder  by  an  ulcerated  open- 
ing.    Here  also  it  is  probable  that  inflammation  was 

*  Guy's  Hosp.  Museum,  No.  1,849  (10). 

"^  Medical  Times  and  Gazette,  vol.  iL,  1872,  page  482. 

+  O0II.  of  Surgeons  Museum,  No.  1,362. 

E— 12 


5©  Intestinal  Obstruction.        [Chap.  hi. 

excited  in  the  pouch  by  the  lodgment  of  a  fsecal 
mass  ;  by  the  peritonitis  set  up  the  process  became 
adherent  to  the  bladder,  and  by  the  extension  of 
ulceration  from  the  diverticulum  the  bladder  was 
perforated.  *  One  of  the  patients  passed  faecal  matter 
by  the  urethra,  while  the  other  f  seems  to  have  been 
more  troubled  by  the  escape  of  urine  into  the  rectum. 

4.  Strangrulatioii  by  normal  structures 
abnormally  attached. 

A.  The  vermiform  appendix  may  become  adherent 
to  some  point  on  the  neighbouring  peritoneum,  and  so 
form  a  band  or  arch  beneath  which  a  loop  of  intestine 
may  be  strangulated.  The  process  is  very  commonly 
adherent  to  the  mesentery  of  the  lower  ileum.  J  Less 
frequently  it  is  adherent  to  the  ileum  itself,§  or  to 
the  caecum,  or  to  the  peritoneum  about  bhe  right  iliac 
fossa  and  margin  of  the  pelvis.  In  one  instance, 
reported  by  Sir  Risdon  Bennet,  the  appendix  was 
adherent  to  an  enlarged  ovary  on  the  right  side,  and 
beneath  the  cord  so  formed  a  loop  of  the  ileum  and  a 
part  of  the  ascending  colon  were  constricted.  || 

In  some  rare  cases  the  appendix  has  been 
described  as  wound  in  the  form  of  a  close  spiral,  or 
of  a  ring  into  which  a  loop  of  intestine  has  entered 
and  has  become  strangulated.  In  other  instances, 
equally  uncommon,  the  appendix  is  said  to  have  tied 
itself  into  an  actual  knot  of  a  character  similar  to 
those  sometimes  formed  by  the  true  diverticulum. 
By  such  a  knot  the  bowel  has  been  constricted. 

It  must  be  confessed  that  this  last-mentioned 
form  of  obstruction  is  a  little  difficult  to  credit.     The 


♦Path.  Soc.  Trans.,  vol.  x.,  page  131 ;  Mr.  Sydney  Jones. 

+  Ibid. ,  vol.  X. ,  page  208  ;  Mr.  Charles  Hawkins. 

t  Guy's  Hosp.  Museum,  No.  2,508  (50). 

%  See  a  good  case  by  Mr.  Gay;  Path.  Soc.  Trans.,  vol.  iii., 
page  101. 

II  Path.  Soc.  Trans.,  vol.  iv.,  page  146.  The  specimen  is  now 
in  St.  Thomas's  Hosp.  Museum,  No.  R  17. 


Chap.  III.]  Fixed  Mesentery.  5.1 

average  length  of  the  appendix  is  three  inches.  It  is 
often  four  or  five  inches,  and  has  been  found  to  reach 
and  even  exceed  the  length  of  eight  inches. 

B.  In  several  instances  the  Fallopian  tube  has  be- 
come adherent  to  some  part  of  the  neighbouring 
peritoneum,  to  that,  for  example,  lining  one  of  the 
iliac  fossae,  and  beneath  the  arcade  so  formed  a  portion 
of  the  small  intestine  has  been  strangulated.* 

0.  A  few  cases  are  reported  where  a  loop  of 
bowel  has  been  strangulated  beneath  a  band  formed 
by  a  fixed  portion  of  the  'mesentery.  In  these  ex- 
amples some  coils  of  the  small  intestine  become  fixed 
at  a  distant  spot.  They  may  be  involved  in  a  large 
irreducible  hernia,  or  may  have  hung  down  into  the 
pelvis,  and  acquired  adhesions  when  in  that  position. 
Under  such  circumstances  the  corresponding  part  of 
the  mesentery  may  become  tightly  stretched  across 
the  posterior  wall  of  the  abdomen  or  the  pelvic  brira, 
and  a  bridge  be  thus  formed  beneath  which  some  of 
the  lesser  bowel  may  become  strangulated,  f  Du- 
chaussoy  appears  to  be  of  opinion,  that  when  a  large 
coil  of  the  ileum  simply  hangs  down  into  the  pelvis, 
the  arch  then  formed  by  the  mesentery  may  be  of 
such  a  character  that  intestine  can  be  obstructed 
beneath  it.  Such  a  circumstance,  however,  must  be 
extremely  exceptional,  in  the  absence  of  any  adhesions 
holding  the  dependent  bowel  in  place.  In  cases  of 
acute  obstruction  it  is  common  enough  to  find  all  the 
coils  of  small  intestine  below  the  point  of  strangula- 
tion hanging  in  a  bunch  empty  and  collapsed  into  the 
pelvis.  If  we  except  these  cases,  however,  there 
must   be  very  few  conditions  met  with  where  large 

*For  cases  see  Bull.  Soc.  Anat,  de  Paris,  1841,  page  209,  by 
M.  Gaubric ;  and  Archiv.  Gen.  de  Med.,  1829,  by  M.  Rostun. 

^  See  case  by  Dr.  Hilton  Fagge  (Guy's  Hosp.  Reports,  vol. 
xiv,),  where  the  Heiim  was  adherent  to  a  tumour  formed  by  an 
extra  uterine  fcetation,  while  beneath  its  tensely  drawn  mesentery 
some  jejunum  was  strangulated. 


52  Intestinal  Obstruction.        [Chap.  hi. 

coils  of  the  bowel  hang  listlessly  in  the  pelvis,  and 
so  form  from  the  mesentery  a  band  sufficiently  long 
abiding  to  allow  gut  to  be  compressed  beneath  it. 
When  such  dependent  coils  are  fixed  or  adherent  the 
mechanism  of  the  obstruction  is  quite  intelligible. 

D.  To  the  bands  formed  by  adherent  appendices 
epiploicce  allusion  has  already  been  made  (page  49). 

E.  Dr.  Hilton  Fagge  has  recorded  the  case  of  a 
woman  aged  seventy-four,  who  died  vdth  symptoms 
of  acute  intestinal  obstruction  that  had  lasted  for  six 
days.  The  autopsy  revealed  a  portion  of  the  ileum 
strangulated  by  the  pedicle  of  a  large  ovarian  cyst. 
On  moving  the  tumour  a  little  the  obstructed  bowel 
was  easily  reduced.* 

5.  StrangnlatJon  throug'h  slits  and  aper- 
tures. 

A.  Slits  and  apertures  in  the  mesentery. — Through 
holes  formed  in  this  membrane  portions  of  intestine  have 
frequently  been  strangulated.  The  holes  are  usually 
slit-like,  and  are  most  common  in  the  mesentery  of  the 
lower  ileum.  In  other  parts  they  are  rare.  In  many 
cases  these  slits  can  be  more  or  less  distinctly  traced 
to  an  injury,  and  several  specimens  in  the  museums  of 
London  show  that  a  limited  rent  of  the  mesentery 
may  be  the  only  visible  lesion  after  violence  applied 
to  the  abdomen.  In  other  cases  there  is  every  reason 
to  believe  that  the  abnormal  aperture  is  congenital. 
The  edges  in  such  instances  are  smooth,  rounded,  and 
regular  ;  there  is  no  history  of  injury  and  no  trace  of 
any  previous  peritonitis.  In  one  case  the  upper 
margin  of  the  slit  appieared  as  a  dense  and  distinct 
band  containing  in  its  substance  a  large  branch  from 
the  superior  mesenteric  artery,  f 

The  hole  is  usually  situated  near  to  the  intestine. 

*  Guy's  Hosp.  Eeports,  vol.  xiv. 

t  Contrib.  a  I'fitude  de  I'Occlusion  Intest.,  by  M.  Le  Moyne. 
Paris,  1878. 


Chap.  III.]  Omental  Apertures.  53 

In  size  it  shows  great  variation.  It  may  be  no  larger 
than  a  sixpenny  piece,"^  or  it  may  be  extensive  enough 
to  admit  four  fingers,  f  In  the  last-mentioned  in- 
stance the  portion  of  bowel  involved  was  the  sigmoid 
flexure,  and  so  far  as  I  can  ascertain  this  is  the  only 
case  on  record  where  colon  has  found  its  way  into 
the  slit.  Mr.  Partridge  has  recorded  a  case,  which 
is  probably  unique,  of  strangulation  of  a  knuckle 
of  ileum  through  an  aperture  in  the  mesentery  of 
the  vermiform  appendix.  \  In  a  few  instances 
the  strangulation  has  occurred  through  slits  in  the 
transverse  and  descending  meso-colon. 

B.  Slits  and  apertures  in  the  omentum. — An 
example  of  this  form  of  obstruction  is  shown  in 
Fig.  17.  §  These  slits  may  be  due  to  congenital 
defect,  but  in  many  instances  they  can  be  distinctly 
traced  to  an  injury.  M.  Le  Fort  reports  the  case  of  a 
young  man  who  developed  symptoms  of  intestinal 
obstruction  some  little  while  after  having  received  a 
kick  on  the  abdomen  from  a  horse.  The  autopsy 
showed  two  hernise  of  portions  of  the  small  intestine 
through  two  slits  in  the  great  omentum. ||  In  speaking 
of  omental  bands  allusion  has  already  been  made  to 
the  circumstance  that  as  a  result  of  violence  a  mass 
of  intestines  may  protrude  through  an  immense  rent 
in  the  omentum,  and  the  two  divisions  of  the 
membrane  thus  formed  may  develop  into  omental 
bands. 

C  Less  common  forms  of  slit. — Mr.  Holmes  has 
placed  on  record  a  remarkable  case,  where  a  loop  of 

*Dr.  Leared  ;  Path.  Soc.  Trans.,  vol.  xiv.,  page  156. 

+  M.  Tr^lat ;  Bull,  et  Mem.  de  la  Soc.  de  CMr.  de  Paris, 
tome  vi ,  1880,  page  594. 

tPath.  Soc.  Trans.,  vol.  xii.,  page  110. 

§University  Coll.  Museum,  No.  1,161.  See  also  specimen  in 
St.  Bai-t.'s  Hosp.  Museum,  No.  2,177. 

II  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  tome  v.,  1869, 
page  635. 


54 


InTES  TINA  L    ObS  TR  UC  TION, 


[Chap.  III. 


the  lower  ileum  was  strangulated  througli  a  hole 
apparently  formed  in  an  appendix  epiploica.  The 
appendix  in  question  was  attached  to  the  sigmoid 
flexure  and  formed  a  fatty  fibrous  ring  through  which 
the  loop  had  passed.     There  were  several  large  and 


Fig.  17. — Strangulation  of  small  Intestine  tLrough  a  Hole  in  the  Great 

Omentum. 

broad  appendices  upon  the  same  segment  of  the  colon, 
some  of  which  were  perforated  near  their  bases,  as  if 
they  also  were  capable  of  developing  into  rings.*  It 
may  be  that  the  appearance  of  a  ring  had  been 
brought  about  by  two  adjacent  appendices  becoming 
adherent  at  their  extremities.      Dr.   Quain  describes 

*  Path.  See.  Trans.,  vol.  xii.,  page  3. 


Chap.  III.]  Sl/ts  and  Aperturrs.  55 

an  autopsy  where  forty  inches  of  the  ileum  wen^ 
found  to  have  passed  through  a  slit  in  the  broad 
ligament  of  the  uterus.  In  this  case,  however,  the 
gut  was  also  held  down  by  a  band  of  old  adhesions.* 
Barth  reports  a  case  of  strangulation  of  the  intestine 
in  a  slit  in  the  suspensory  ligament  of  the  liver,  f 
The  small  intestine  has  not  infrequently  been  found 
to  have  passed  through  the  foramen  of  Winslow,  and 
Leichtenstern  has  collected  three  cases  where  the  gut 
so  placed  became  strangulated  by  the  margins  of  the 
aperture. 

In  by  no  means  a  few  instances  a  coil  of  intestine 
has  been  contracted  by  passing  through  a  slit  formed 
in  a  broad  membranous  adhesion.  In  other  cases  the 
bowel  has  protruded  between  two  cord-like  adhesions 
placed  close  together  and  parallel  with  one  another. 
Mr.  Hutchinson  mentions  an  instance  where  the  slit 
was  formed  between  a  false  ligament  and  the  edge  of 
the  broad  ligament  of  the  uterus,  by  the  side  of  which 
the  adhesion  ran.  \  In  some  cases  rings  and  slits 
have  been  formed  between  intestinal  loops  that  have 
become  matted  together,  and  through  these  apertures 
a  non-adherent  coil  has  passed  and  become  constricted. 
In  one  case,  briefly  mentioned  by  Sir  Astley  Cooper, 
it  was  found  that  "  two  folds  of  intestine  had  adhered 
at  one  point  only  (as  may  be  represented  by  bringing 
the  points  of  the  thumb  and  finger  in  contact) ;  through 
the  noose  thus  formed,  another  fold  of  intestine  was 
passed  and  had  become  strangulated."  §  The  occa- 
sional gaps  and  slits  that  may  be  formed  between 
adherent  intestines,  and  the  viscus  or  parietes  to  which 
they  are  attached,  may  serve  as  holes  through  which  a 
coil  of  bowel  may  pass  and  be  constricted. 

*Patli.  Soc.  Trans.,  vol.  xii.,  page  103. 
t  Schmidt's  Jalirb.,  b.  96,  s.  207. 
%  Med.  Times  and  Gazette,  1858. 
§  Abdominal  Hernia,  chap.  xxs.v. 


56  Intestinal  Obstruction.         [Chap.  hi. 

Into  the  complicated  subject  of  internal  hernise 
there  is  no  occasion  to  enter  in  this  work.  Of  the 
numerous  varieties  described,  one  only  is  at  all 
common,  the  diaphragmatic  form ;  and  diaphragmatic 
hernia,  it  must  be  owned,  has  little  to  do  either 
clinically  or  pathologically  with  intestinal  obstruction. 

Of  the  other  varieties,  such  as  the  hernia  meso- 
colica,  the  hernia  intrailiaca,  the  hernia  intersigmoidea, 
and  the  like,  it  need  only  be  said  that  they  are  very 
rare,  that  they  become  the  seat  of  a  strangulation 
still  more  rarely,  and  that  whether  strangulated  or 
not  strangulated,  they  cannot  be  diagnosed  during  life. 
Should  the  portion  of  intestine  that  they  contain 
become  constricted,  the  symptoms  induced  would  be 
similar  to  those  of  strangulation  under  a  band,  while 
the  treatment  of  the  two  cases  would  be  practically 
identical. 

RELATIVE  FREQUENCY  OF  THE  VARIOUS  FORMS  OF 
STRANGULATION  DEPENDING  UPON  BANDS,  APER- 
TURES,   ETC. 

The  seven  most  common  forms  met  with  under 
this  heading  may  be  arranged  in  the  following  order 
of  frequency  : 

1.  Strangulation  under  isolated  peritoneal  adhesions         =  60 

2.  Strangulation  under  diverticula  and  diverticular  bands  =1  40 

3.  Strangulation    by    knots    and    nooses    formed     by^ 
"bands  " 

4.  Strangulation  by  knots  and  nooses  formed  byy=:25 
diverticula 

5.  Strangulation  under  an  adherent  appendix  J 

6.  Strangulation  through  slits  in  the  omentum  ^  20 

7.  Strangulation  under  omental  ligaments  =  15 

The  figures  may  be  taken   as  representing   the  probable  relative 
frequency  of  the  various  forms. 

THE    PORTION    OF    INTESTINE    INVOLVED. 

In  the  form  of  intestinal  obstruction  now  under 
consideration,  although  many  very  different  methods 


Clap.  III.]       Strangulation  BY  Bands.  57 

are  concerned  in  the  production  of  that  obstruction, 
the  part  of  the  alimentary  tube  involved  is,  with 
scarcely  an  exception,  the  same,  viz.  the  small  in- 
testine. 

A  case  has  already  been  incidentally  alluded  to 
where  a  part  of  the  ascending  colon  was  found  com- 
pressed beneath  an  adherent  vermiform  appendix,  and 
another  where  a  loop  of  the  sigmoid  flexure  was 
strangulated  through  a  rent  in  the  mesentery. 

Instances  may  be  given  where  a  part  of  the  colon 
has  been  obstructed  beneath  a  tightly  drawn  mesen- 
tery (Duchaussoy),  together  with  a  few  other  isolated 
observations  of  the  same  character.  So  extremely 
rare,  however,  is  it,  for  any  part  of  the  colon  to  be 
involved  in  the  present  variety  of  intestinal  obstruc- 
tion, that,  so  far  as  the  general  bearings  of  the  whole 
subject  are  concerned,  the  few  reported  cases  may  be 
regarded  as  pathological  curiosities.  If  it  be  borne  in 
mind  that  the  hernia-like  strangulation  of  the  bowel 
requires  that  the  gut  to  be  involved  should  be  quite 
free  and  movable,  and  that  it  should  be  capable  also 
of  readily  forming  a  knuckle  or  loop,  it  will  be  seen 
that  no  part  of  the  normal  colon,  if  we  except, 
perhaps,  the  sigmoid  flexure,  has  a  disposition  that 
will  allow  it  to  share  in  this  form  of  obstruction. 

In  the  great  majority  of  all  cases  the  segment  of 
small  intestine  involved  is  the  lower  part  of  the 
ileum.  In  a  fair  number  of  instances  the  middle  and 
upper  portions  of  the  ileum  have  been  involved,  but 
the  examples  of  strangulation  of  the  jejunum  by  the 
methods  now  under  consideration  are  comparatively 
rare.  Indeed,  it  may  be  said  that,  as  one  follows  the 
small  gut  from  the  csecum  to  the  pylorus,  every  foot 
of  the  distance  renders  the  probability  of  strangula- 
tion more  and  more  unlikely.  I  believe  that  there 
is  no  recorded  instance  of  implication  of  the  duodenum 
in  this  form  of  obstruction ;  and,  indeed,  it  would  be 


58  Intestinal  Obstruction.        [Chap.  hi. 

anatomically  impossible  for  the  "  third  part "  of  that 
segment  of  the  bowel  to  be  involved. 

The  frequency  with  which  the  last  few  feet  of  the 
ileum  are  involved  is  very  intelligible.  The  coils  of 
the  lower  ileum  are  the  parts  of  the  small  intestine 
most  apt  to  be  found  in  the  pelvis,  and  to  be  thus 
ensnared  by  those  many  adhesions  that  may  result 
from  pelvic  peritonitis.  They  are,  moreover,  in  the 
closest  association  with  the  csecum  and  appendix,  and 
are  most  likely,  therefore,  to  be  strangulated  by 
adhesions  that  may  follow  upon  typhlitis,  and  by  the 
cord  formed  by  the  vermiform  appendix  when  it 
becomes  adherent.  Then,  again,  the  true  diverticulum 
arises  from  the  lower  ileum,  and,  as  may  be  expected, 
the  obstructions  that  it  causes  have,  with  compara- 
tively few  exceptions,  their  seat  in  the  last  few  feet  of 
the  lesser  bowel*  In  strangulation  due  to  this 
process  the  part  of  the  ileum  involved  may  be  either 
that  above  or  that  below  the  origin  of  the  abnormal 
appendage.  In  most  cases  that  portion  of  the  bowel 
is  engaged  that  lies  between  the  diverticulum  and  the 
csecum.  It  must  also  be  noted  that  abnormal  apertures 
in  the  mesentery,  or  such  at  least  as  are  supposed  to 
be  of  congenital  origin,  are  most  often  found  in 
that  part  of  the  membrane  that  is  connected  with  the 
lower  ileum.  This  part  of  the  bowel,  moreover,  is 
often  involved  in  hernise  of  the  right  side,  and  may 
suffer  in  any  trouble  due  to  bands  of  adhesion  follow- 
ing upon  complicated  ruptures.  Lastly,  it  is  to  be 
observed,  that  while  any  coil  of  small  intestine  taken 
from  the  upper  ileum  or  jejunum  would  be  equally 
movable  at  both  ends,  one  end  of  the  terminal  part 

*  I  have  not  been  able  to  find  any  case  where  a  part  of  the 
small  intestine  has  been  involved  in  obstruction  due  to  the  diver- 
ticulum other  than  the  ileum.  The  obstructed  coil  may  not  have 
been  always  a  'part  of  the  last  few  feet  of  the  gut,  but  it  has  still 
always  been  well  within  the  limits  of  the  ileum. 


Chap.  III.]       Strangulation  BY  Bands.  50 

of  the  ileum,  on  the  other  hand,  is  more  or  less  fixed 
by  its  connection  with  the  caecum. 

As  to  the  aviount  of  small  intestine  that  may  be 
involved  in  a  strangulation,  the  greatest  variety  exists. 
The  involved  piece,  on  the  one  hand,  may  be  so  small 
that  only  one  half  of  the  circumference  of  the  gut  is 
nipped,"^  while  on  the  other  hand  it  may  measure 
four  feet.  Every  possible  variety  exists  between  these 
two  extremes.  Taking  an  average  of  forty -five  cases 
where  the  amount  of  bowel  involved  is  stated,  I  find 
that  it  reaches  15 '5  inches.  The  amount  involved 
depends  a  great  deal  more  upon  the  mechanism  of  the 
strangulation  than  upon  the  anatomical  cause  of  it. 
"When  the  obstruction  is  due  to  strangulation  under  a 
band  or  through  a  slit  the  average  amount  of  bowel 
involved  is  small,  often  a  mere  knuckle.  When,  on 
the  other  hand,  the  strangulation  is  brought  about  by 
knots  and  nooses,  it  is  usually  found  that  large  coils 
are  involved,  it  being  impossible,  under  ordinary 
circumstances,  for  a  little  loop  of  bowel  to  be  so 
strangulated. 

To  these  general  observations  there  are,  of  course, 
many  exceptions.  For  example,  one  of  the  cases  in 
which  an  unusually  large  amount  of  intestine  was 
strangulated  was  a  case  of  strangulation  under  an 
adherent  vermiform  appendix,  in  which  instance  four 
feet  of  ileum  were  found  to  be  implicated,  f  Exam- 
ples, also,  of  strangulation  of  two  and  even  three  feet 
of  bowel  beneath  a  band  are,  although  exceptional,  by 
no  means  uncommon. 

THE   MECHANISM    OF   THE    OBSTRUCTION. 

The  actual  mechanism  of  the  obstruction  varies  a 
little  in  different  cases.     In  many  instances,  no  doubt, 

*  Case  of  strangulation  under  an  omental  band,  by  Dr.  J. 
Boeckel ;  Bvill.  et  M^m.  de  la  Soc.  de  CMr.,  tome  iv.,  1880,  page  339. 
t  Dr.  Hilton  Fagge ;  Guy's  Hosp.  Reports,  vol.  xiv. 


6o  Intestinal  Obstruction.        rchap.  hi. 

a  knuckle  or  coil  of  gut  is  driven  with  such  sudden  and 
severe  force  beneath  a  band  or  through  an  aperture 
as  to  become  practically  strangulated  at  once,  just  as 
is  the  case  in  strangulated  hernia,  when  the  symp- 
toms appear  abniptly  during  some  unwonted  exertion. 
No  force  of  equal  magnitude  being  brought  to  bear 
upon  the  part  so  as  to  eifect  its  reduction,  it  remains 
firmly  gripped.  When  a  comparatively  large  mass  of 
intestine  is  involved,  the  strangulation  need  not  be 
present  from  the  first.  But  the  band  pressing  upon 
the  mesenteric  vessels  produces  a  congestion  in  the 
involved  coils  until  at  last  the  engorgement,  aided  by 
increasing  distension  of  the  loop  itseK,  leads  to  a 
complete  strangulation. 

It  must  be  observed  also  that  engorgement  of  the 
veins,  and  a  diminution  in  the  arterial  blood  supply 
of  the  gut,  with  consequent  deficiency  of  oxygen  and 
excess  of  carbonic  acid  in  such  blood  as  occupies  the 
intestinal  walls,  induces  inordinate  activity  of  the 
peristaltic  movements.  It  is  probable  that  these 
violent  movements  materially  aid  in  producing  a 
strangulation. 

Many  cases  are  on  record,  from  the  accounts  of 
which  it  is  to  be  inferred  that  vascular  distension  has 
been  a  conspicuous  factor  in  completing  the  obstruc- 
tion ;  cases  where  much  gut  is  involved,  where  the 
mesentery  is  extensively  compressed,  and  where  a 
bloody  fluid  in  the  peritoneum,  or  many  "haemorrhages 
beneath  the  serous  coat,  point  to  the  severity  of  the 
congestion  that  preceded  actual  stopping  of  the  circu- 
lation. Increasing  distension,  moreover,  of  the 
implicated  bowel  must  always  be  an  important 
feature.  This  distension  is  due  not  only  to  matters 
passed  into  the  partly  occluded  intestine  from  above, 
but  also  to  gas  developed  within  the  strangulated  and 
paralysed  loop.  Certain  simple  experiments  throw 
some  light  upon  the  matter.     M.  Le  Moyne  opened 


Chap.  111.]       Strangulation  BY  Bands.  6i 

the  abdomen  in  the  cadaver,  and  having  drawn  a 
little  loop  of  the  small  intestine  through  a  slit  made 
in  the  mesentery,  replaced  the  gut  so  arranged  and 
closed  the  abdominal  wound.  He  then  made  a 
second  incision  into  the  belly  at  a  remote  spot,  and 
injected  water  or  semi-fluid  matter  into  the  small 
intestine  above  the  seat  of  the  obstruction.  The  first 
matter  that  reached  the  loop  in  the  mesentery  passed 
through  it,  but  as  more  was  injected  the  little  coil 
became  rapidly  distended,  and  was  ultimately  closed 
and  entirely  obstructed,*  M.  Anger,  experimenting 
in  another  direction,  drew  a  loop  of  gut  out  of  the 
abdomen,  and  put  a  ligament  lightly  around  its  two 
ends.  The  ligature  was  loose  enough  to  allow  the 
gut  to  slide  about  within  it,  and  to  allow  the  tip  of 
the  little  finger  to  be  introduced  into  each  end  of  the 
bowel.  He  then  made  a  hole  at  the  bend  of  the  loop, 
at  the  part  most  remote  from  the  ligature,  and  intro- 
duced a  tube,  through  which  air  was  blown.  As  the 
gut  distended  some  air  escaped,  but  the  more  swollen 
it  became  the  more  tightly  was  it  gripped,  until  when 
fully  distended  it  was  found  to  be  hermetically  sealed ; 
and,  what  is  more  interesting,  more  gut  had  been 
drawn  into  the  loop  from  the  abdomen.^ 

In  a  great  many  cases  the  final  cause  of  the  stran- 
gulation is  a  twisting  of  the  involved  coil  of  bowel. 
This  is  well  shown  in  several  museum  specimens. 
Here  the  band  would  not  have  been  of  itself  sufficient 
to  produce  a  strangulation  provided  that  the  bowel 
had  not  become  twisted  beneath  it.  On  the  other 
hand,  it  is  equally  obvious  that  the  volvulus  could  not 
have  been  produced  without  the  band.  The  twist  is 
given  to  the  bowel  partly  by  distension,  partly  by  its 

*  Contrib.  a  I'E^ude  de  I'Occlusion  Intestinale,  by  M.  Lo 
Moyne.     These  de  Paris,  1878. 

fDe  i'Etranglemeut  Intestinale,  by  M.  Benjamin  Anger. 
These  de  Paris,  1865. 


62  Intestinal  Obstruction.         [Chap.  it. 

own  movements,  partly  by  the  dragging  of  the  mesen- 
tery. In  some  cases,  adhesions  already  existing  above 
the  implicated  coil  may  have  favoured  the  volvulus. 
There  must  be  cases  also,  similar  to  that  illustrated  in 
Fig.  2,  where  the  arrangement  of  the  band  is  such,  that 
it  could  never  strangulate  the  bowel  luitil  the  bowel 
itself  had  become  twisted. 

There  are  instances  also  where  the  arrangement 
of  the  band  and  of  the  mesentery  are  such,  that  the 
engaged  loop  as  it  becomes  distended  is  soon  so 
acutely  bent  over  the  band  by  the  dragging  of  the 
mesentery  that  it  becomes  obstructed  (in  one  end  of 
the  loop  at  least)  before  it  is  very  tightly  gi'ipped. 


CHAPTER    TV. 

STRANGULATION  BY  BANDS  OR  THROUGH  APERTURES. 

SYMPTOMS. 

Frequency. — The  cases  that  come  under  this 
category  form  no  less  than  one  fourth  of  the  total 
number  of  cases  of  intestinal  obstruction  from  all 
causes.* 

The  high  proportion  here  indicated  depends  partly 
upon  the  fact  that  several  distinct  anatomical  con- 
ditions are  comprised  under  one  general  heading,  and 
partly  upon  the  circumstance  that  a  comparatively 
common  ailment  (local  peritonitis)  takes  an  im- 
portant part  in  the  production  of  the  different 
forms  of  the  obstructing  agent. 

Sex. — This  variety  of  obstruction  of  the  bowels  is 
more  common  in  males  than  in  females  in  the  pro- 
portion of   180  to   118.     The    distribution    of    these 

*  From  this  enumeration  are  excluded  hernise  and  affections 
of  the  rectum,  both  congenital  and  acquired. 


Males. 

Females, 

52 

59 

43 

15 

52 

14 

21 

13 

Chap.  IV.]        Strangulation  BY  Bands.  63 

figures  among    the    different    sub-varieties  is  shown 
in  tiie  following  table  from  Leichtenstern  : 

Strangulation  hy  false  ligaments   . 
,,  by  the  omentum 

„  by  the  diverticle 

„  by  the  appendix  vermifonnis  . 

„  .'throug-h  sKts  in  the  mesentery 

and  in  other  parts,  occluding  the  omentum         12  17 

180  118 

It  will  be  seen  that  strangulation  by  peritoneal 
adhesions  occurs  with  about  equal  frequency  in  the 
two  sexes.  The  balance,  however,  is  very  strangely 
struck.  THe  two  forms  of  peritonitis  that  are  an- 
swerable for  the  bulk  of  the  adhesions  that  cause 
strangulation  are  pelvic  peritonitis,  and  the  peritoneal 
inflammation  associated  with  typhlitis.  Pelvic  peri- 
tonitis is  practically  limited  to  women,  and  in  the 
matter  of  strangulations  due  to  pelvic  adhesions 
females  are  of  course  enormously  ahead  of  the  males. 
Typhlitis,  on  the  other  hand,  is  much  more  common 
in  males  than  in  females,  the  ratio  being,  according  to 
Bamberger,  twenty-six  to  four.  The  cases,  however, 
of  false  ligaments  due  to  pelvic  inflammation  out- 
number those  due  to  inflammation  of  the  caecum,  and 
the  balance  between  the  two  sexes  is  made  nearly 
even  by  the  increased  frequency  of  hernia  in  the  male, 
and  by  the  greater  liability  to  peritonitis  from  violence 
in  members  of  that  sex. 

The  disproportion  in  the  number  of  the  cases 
among  males  and  females  due  to  strangulation  by  the 
omentum  is  readily  explained.  Owing  to  its  limited 
length  the  omentum  can  contract  adhesions  about  the 
right  iliac  fossa  (typhlitis)  with  somewhat  greater 
ease  than  about  the  pelvis.  This  circumstance  would 
render  omental  adhesions  a  little  more  frequent  in 
men.     A  more  influential  factor,  however,  is  concerned. 


64  Intestinal  Obstruction.         [Chap.  iv. 

The  omental  adhesions  are  very  commonly,  perhaps 
most  commonly,  brought  about  by  external  hernise, 
and  Mr.  Kingdon's  tables  show  that  for  all  ages 
and  all  varieties,  rupture  is  twice  as  common  among 
males  as  it  is  among  females.  The  formation  of 
omental  cords  after  injury  must  also  be  taken  into 
consideration. 

With  regard  to  the  diverticula,  it  is  simply  a 
matter  of  anatomical  observation  that  they  occur  with 
much  greater  frequency  in  the  male  than  in  the 
female  sex.  Their  situation  about  the  csecal  region 
would  also  render  the  shorter  of  them  more  liable  to 
form  adhesions  after  typlilitis  than  after  pelvic 
peritonitis. 

The  gi'eater  frequency  of  strangulation  by  the 
appendix  vermiformis  in  males  is  explained  by  the 
ease  with  which  that  process  becomes  adherent  after 
typhlitis,  typhlitis  being  certainly  the  most  common 
cause  of  adherent  appendix. 

The  distribution  of  the  few  cases  of  strangulation 
through  mesenteric  and  other  slits  and  apertures  calls 
for  little  comment.  The  slightly  increased  frequency 
in  the  female  sex  may  possibly  be  due  to  the  cir- 
cumstance that  obstruction  through  slits  in  broad 
adhesions  has  been  met  with  most  often  in  the  pelvis 
among  the  results  of  peritonitis  in  that  region. 

Age. — Strangulation  by  false  ligaments,  by  the 
omentum,  by  the  appendix,  and  through  abnormal 
slits  and  apertures  occurs  most  frequently  in  persons 
between  the  ages  of  twenty  and  forty.  This  circum- 
stance obviously  depends  upon  the  fact  that  the  forms 
of  peritonitis,  with  which  these  affections  are  so 
intimately  associated,  are  most  common  between  these 
ages.       Typhlitis    falls    within    this   period   of    life."* 

»  "  Typhlitis  occurs  most  frequently  between  the  ages  of  16 
and  35."  Bauer;  Ziemssen's  Cyclopaedia  of  Medicine,  vol.  viii., 
page  317. 


Chap.  IV.]       Strangulation  BY  Bands.  65 

Pelvic  peritonitis  occurs,  with  comparatively  few 
exceptions,  during  the  period  of  child-bearing,  and  as 
a  rule  early  in  that  period,  being  frequent  in  primi- 
parse.  Mr.  Kingdon's  tables  show  that  the  gi'eatest 
number  of  cases  of  hernia  appear  for  the  first  time 
during  the  twenty  years  in  question.  During  the 
same  period  also  strangulation  of  hernise  is  common, 
and  perhaps  at  no  other  period  of  life  are  injuries  of 
a  severe  character  more  frequent. 

Many  cases  are  met  with  after  forty.*  Forms  of 
peritonitis  that  may  be  recovered  from,  and  that  lead 
to  adhesions,  may  occur  after  that  age,  and,  moreover, 
strangulation  of  the  bowel  may  not  occur  for  many 
years  after  the  peritonitis  that  renders  it  possible 
has  passed  away. 

Before  twenty  these  varieties  of  obstruction  are 
comparatively  uncommon,  and  before  ten  they  are 
very  rare.  In  one  or  two  cases  of  incarceration  by  a 
false  ligament  in  young  children,  the  formation  of  the 
adhesion  has  probably  depended  upon  an  intra-uterine 
inflammation.  Children  are  not  liable  to  those  forms 
of  peritonitis  that  can  be  recovered  from.  In  such 
subjects  typhlitis  is  quite  rare  and  pelvic  peritonitis 
practically  unknown.  Infantile  peritonitis  and  the 
tubercular  form  of  the  disease  are  uniformly  fatal; 
although  during  the  course  of  the  more  chronic  forms 
of  the  latter  affection  strangulation  may  occur.  Thus 
M.  Larguier  des  Bancels  reports  the  case  of  a  boy, 
aged  eight,  who  during  the  progress  of  tubercular 
peritonitis  developed  symptoms  of  acute  obstruction, 
of  which  he  soon  died.  The  autopsy  revealed  a  coil 
of  the  lower  ileum  strangulated  by  a  band,  one  of  the 
many    resulting    from    the    disease    of     the    serous 

*  The  oldest  patient  of  whom  I  can  find  record  is  a  woman 
aged  80,  who  died  of  acute  obstruction  due  to  an  omental  band 
after  hernia.     Lucas-Champoinniere ;  Bull,  et  Mem.  de  la  Soc.  de 
Chir.  de  Paris,  tome  v.,  1879,  page  645. 
F— 12 


66  Intestinal  Obstruction.         [Chap.  iv. 

membrane."^  When,  therefore,  strangulation  due  to 
adhesions  is  met  with  in  the  young,  it  is  usually  found 
that  the  adhesions  have  followed  injury,  or  the  slight 
peritonitis  that  may  attend  caseous  degeneration  of 
the  mesenteric  glands.  The  main  number,  however, 
of  the  cases  of  incarceration  coming  under  the  present 
general  category  are  such  as  depend  upon  congenital 
abnormalities. 

Strangulation  by  means  of  the  true  diverticulum  oc- 
curs most  frequently  during  the  twenty  years  between 
10  and  30.  Of  the  two  decades  the  latter  presents 
the  greater  number  of  cases.  Leichtenstern  found 
the  average  age  in  seventy  cases  to  be  2.5  years.  He 
notes  eight  cases  between  the  ages  of  2  and  10  years, 
and  Trier  has  recorded  a  case  in  an  infant  of  8 
months.!  Above  the  age  of  40  strangulations  due  to 
the  diverticulum  are  extremely  rare.  Incarceration 
by  this  process  is  to  a  great  extent  independent  of 
peritonitis,  since  it  can  occur  without  the  aid  of 
acquired  adhesions.  Moreover,  when  a  free  process 
does  acquire  an  attachment  it  seems  to  be  capable  of 
doing  so  without  inducing  a  peritonitis  of  appreciable 
magnitude.  A  diverticular  pouch  or  ligament,  once 
free,  is  often  found  adherent  to  some  spot  on  the 
serous  membrane,  while  about  that  spot  no  trace  of  a 
previous  inflammation  will  be  found. 

[The  account  of  the  symptoms  that  follows  is 
founded  mainly  upon  an  analysis  of  fifty  recorded 
cases  of  this  form  of  obstruction.  These  fifty  cases 
were  selected  from  a  larger  number,  upon  the  sole 
ground  that  the  accounts  of  them  were  more  or  less 
complete,  both  clinically  and  pathologically.  Im- 
perfectly reported  cases  are,  when  not  simply  useless, 
actually  misleading.] 

*  Sur  le  Diagnostic  et  le  Traitement  Chirurgical  des  Etranglc- 
ments  Internes.     These  de  Paris,  1870. 
tPfaff's  Mittheil.,  Jahrg.  iii.,  Heft  9. 


Chap.  IV.]        Strangulation  BY  Bands,  67 

The  previous  history. — This  is  a  matter  of 
some  importance  in  tlie  diagnosis,  and  may  be  con- 
sidered under  two  heads :  1.  History  of  previous 
peritonitis,  injury,  etc.,  i.e.  of  circumstances  that 
may  have  rendered  an  obstruction  possible  :  2. 
History  of  previous  attacks  of  abdominal  disturbance, 
i.e.  of  symptoms  such  as  may  have  been  produced  by 
the  same  cause  that  brought  about  the  final  strangula- 
tion. 

1.  Out  of  the  fifty  cases  above  alluded  to,  there 
was  in  thirty-four  instances  (68  per  cent.)  a  history  of 
such  previous  trouble  as  may  have  produced  causes 
for  obstruction.  In  seventeen  cases  (34  per  cent.) 
there  was  a  history  of  peritonitis ;  in  eleven  (22  per 
cent.)  a  history  of  hernia;  in  six  (12  per  cent.)  a 
history  of  accident.  In  sixteen  cases  (32  per  cent.) 
there  was  nothing  in  the  previous  history  to  note 
under  this  heading.  These  sixteen  cases  included 
several  examples  of  the  diverticulum,  some  in- 
stances of  slit  in  the  mesentery,  and  a  few  patients 
in  whom  adhesions  had  been  found  without  any 
circumstances  in  their  previous  history  to  call  atten- 
tion to  the  occurrence. 

As  to  the  interval  of  time  that  may  have  elapsed 
between  the  causative  afiection  and  the  actual  strangu- 
lation, the  greatest  variety  exists.  The  shortest  period 
I  have  noticed  is  in  a  case  where  only  five  weeks 
elapsed  between  the  peritonitis,  that  presumedly 
formed  the  band,  and  the  strangulation  of  the  bowel. 
The  longest  period  was  met  with  in  a  female  aged  52, 
who  died  of  strangulation  of  the  ileum  by  a  band 
connected  with  the  pelvic  peritoneum.  Twenty-one 
years  before  she  had  had  "inflammation  of  the  womb" 
following  labour."^  In  two  cases,  next  to  this  in  point 
of  time,  seven  years  had  elapsed.  Omitting  the 
twenty-one  years'  case,  the  average  duration  of  the 
*  Guy's  Hospital  Keports,  vol.  xiv.,  page  272. 


68  Intestinal  Obstruction.        [Chap.  iv. 

interval  between  the  causative  peritonitis  and  the  ob- 
struction was  three  years. 

With  regard  to  internal  strangulations,  due  directly 
to  hernia,  they  were  in  all  cases  observed  in  connec- 
tion with  ruptures  of  many  years'  standing.  In  one 
patient  aged  80,  who  died  of  incarceration  of  the 
bowel  by  an  omental  band,  the  hernia  with  which 
that  band  was  associated  had  existed  for  sixty  years. 

In  the  twelve  cases  where  an  accident  is  credited 
with  being  the  existmg  cause  of  a  strangulation,  the 
interval  between  the  lesion  and  the  intestinal  trouble 
was  in  all  cases  short,  and  in  two  instances  the 
development  of  strangulation  was  immediate. 

2.  Some  of  the  patients  who  had  died  of  obstruc- 
tion had  complained  of  previous  intestinal  troubles, 
such  as  severe  indigestion,  ''spasms,"  bilious  attacks 
and  persistent  pains  in  the  abdomen.  The  number  of 
individuals  in  whom  such  symptoms  had  been  noticed 
was  comparatively  few,  and  it  is  questionable  whether 
such  symptoms  were,  or  were  not,  dependent  upon 
the  same  cause  that  ultimately  brought  about  the 
obstruction.  It  can  only  be  surmised  that  when 
adhesions  are  attached  to  the  bowel  itself  they  may, 
from  traction  or  other  causes,  embarrass  at  times  the 
peristaltic  movement  of  the  intestine  and  hinder  the 
progress  of  its  contents. 

In  six  individuals  (12  per  cent.)  there  was  a 
history  of  previous  obstruction.  These  attacks  were 
marked  by  the  onset  of  a  sudden  and  severe  pain  of 
a  colicky  character,  associated  with  vomiting  and  con- 
stipation. Their  duration  was,  as  a  rule,  quite  short, 
varying  from  one  to  three  days.  Usually  there  had 
been  only  one  such  attack  previous  to  the  final  one. 
In  rarer  instances  there  had  been  two  or  three.  In 
some  examples  these  previous  attacks  had  been  very 
severe.  Mr.  Gay  has  given  details  of  the  case  of  a 
man  aged  42,  who  died  from  strangulation  of  a  coil  of 


Chap.  IV.]        Strangulation  BY  Bands.  69 

ileum  beneath  an  adherent  appendix.  Durmg  the 
four  years  that  preceded  his  death,  the  patient  had  had 
no  less  than  thirty  attacks  of  severe  pain,  associated 
with  vomiting  and  absolute  constipation.  This  case, 
however,  was  complicated  by  a  stricture  of  the  small 
intestine,  to  the  occasional  plugging  of  which  these 
thirty  attacks  were  probably  due."^  The  rarity  of 
previous  attacks  in  this  form  of  intestinal  obstruction 
compares  strikingly  with  the  great  frequency  of  such 
occurrences  in  many  of  the  more  chronic  forms  of 
obstruction. 

The  mode  of  onset.— The  attack,  as  a  rule, 
begins  suddenly  with  very  severe  abdominal  pain, 
followed  rapidly  by  vomiting  and  symptoms  of  consti- 
tutional depression.  On  analysing  fifty  cases,  I  find 
that  in  thirty-five  instances  (70  per  cent.)  the  mode 
of  onset  was  more  or  less  distinctly  sudden.  In  thir- 
teen cases  it  was  comparatively  gradual,  and  in  the 
remainino-  two  observations  the  commencement  of  the 
attack  is  not  described. 

A  study  of  the  pathology  of  this  form  of  obstruc- 
tion would  lead  one  to  infer  that  its  onset  would  be 
sudden.  A  loop  or  knuckle  of  gTit  is,  in  a  moment, 
thrust  beneath  a  band,  or  through  an  aperture,  or  is 
snared  by  a  free  noose  or  knot,  and  symptoms  of 
strangrdation  follow  almost  directly.  An  examination 
of  the  cases  of  gradual  onset  often  reveals  some  cir- 
cumstance that  may  account  for  this  somewhat 
unusual  mode  of  commencement.  In  some  instances 
the  symptoms  of  absolute  obstruction  followed  upon 
prolonged  constipation,  and  the  condition  of  the  parts 
involved  seems  then  to  have  borne  the  same  relation 
to  the  conditions  of  acute  strangulation  that  an  "  ob- 
structed hernia "  bears  to  a  strano-ulated  one.  In 
one  case  the  intestines  were  so  matted  together  by 
numerous  adhesions,  that  partial  obstruction  may 
*  Path.  Soc.  Ti-ans.,  vol.  iii.,  page  101. 


70  Intestinal  Obstruction.        [Chap.  iv. 

have  taken  place  at  many  points  at  once,  so  that  the 
final  incarceration  would  be,  in  a  sense,  cumuliitive. 
In  another  instance  of  gradual  onset,  a  loop  of  the 
ileum  and  a  part  of  the  ascending  colon  were  beneath 
the  band,  the  large  bowel  apparently  affording  some 
temporary  protection  to  the  small.  In  other  cases  it 
would  appear  that  a  large  quantity  of  intestine  had 
passed  beneath  a  band,  but  had  not  been  at  first 
tightly  nipped  by  it.  In  such  examples  complete 
strangulation  would  follow  slowly  upon  the  gradual 
distension  and  engorgement  of  the  compressed  coils. 

In  the  instances  where  the  onset  has  been  gradual, 
the  patient  has  usually  had  some  slight  pain,  often  of 
an  intermittent  character,  with  trifling  vomiting,  and 
a  constipation  that  has  frequently  not  been  absolute. 
Very  soon,  however,  the  symptoms  increase  in  severity 
and  assume  all  the  characters  of  those  of  acute  strangu- 
lation. The  transition  from  subacute  symptoms  to 
acute  is  often  coincident  with  the  administration  of 
strong  aperients. 

Evidence  of  any  immediate  exciting^  cause 
is  very  commonly  absent.  In  probably  about  two- 
thirds  of  the  cases  the  attack  seems  to  have  come  on 
when  the  patient  was  in  good  health,  or  at  least  free 
from  any  abdominal  disturbance.  In  three  cases  (out 
of  fifty),  it  set  in  suddenly  during  the  night  while  the 
patient  was  asleep.  In  about  one-third  of  the  cases 
some  circumstances  have  immediately  preceded  the 
symptoms  of  strangulation  that  may  have  taken  an 
active  part  in  producing  the  obstruction.  The  fallacy, 
however,  of  the  argument,  "  post  hoc  propter  hoc,"  may 
enter  into  many  of  these  relations,  or  the  supposed 
exciting  cause  may  have  been  really  a  part  of  the 
symptoms  of  the  final  malady.  This  would,  perhaps, 
apply  to  those  instances  where  strangulation  has  fol- 
lowed upon  a  "  bilious  attack  "  or  upon  severe  "  indi- 
gestion."    Putting  these  cases  aside,  however,  we  find 


Chap.  IV.]       Strangulation  by  Bands.  71 

that  the  obstruction  has  several  times  appeared  after 
a  hearty  meal,  and  especially  a  meal  of  indigestible 
food,  such,  for  example,  as  beans.  In  connection 
with  hernia,  it  has  come  on  when  the  rupture  was 
down  or  giving  trouble.  In  two  instances  it  appeared 
while  straining  at  stool.  In  one  or  two  cases  it  came 
on  after  the  administration  of  a  purge.  It  has  followed 
also  upon  a  sharp  attack  of  diarrhoea.  In  quite  a  fair 
number  of  patients  the  symptoms  of  strangulation 
have  made  their  appearance  either  during  or  imme- 
diately after  unusual  exertion.  In  one  instance  a 
peculiar  position  of  the  body  seems  to  have  had  some 
influence,  as  illustrated  by  the  case,  reported  by  Dr. 
Quain,  where  a  coil  of  ileum  was  found  strangulated 
through  a  slit  in  the  broad  ligament  of  the  uterus. 
Here  the  attack  came  on  suddenly  while  the  patient 
was  bending  to  unlace  her  boots.  In  a  remarkable 
case  reported  by  Mr.  Bryant,  a  distended  bladder  was 
the  immediate  cause  of  a  strangulation  being  pro- 
duced. In  this  instance  a  coil  of  bowel  was  involved 
beneath  a  band  that  passed  from  the  bladder  to  the 
lumbar  spine.  The  patient  had  been  out  for  a  drive 
and  had  been  compelled  to  retain  her  urine  for  some 
hours.  Shortly  after  emptying  her  bladder,  symptoms 
of  acute  obstruction  set  in.  Here  there  is  little  doubt 
but  that  the  distended  viscus  so  raised  the  band  out 
of  the  pelvis  as  to  allow  a  loop  of  gut  to  pass  beneath 
it.* 

The  pain. — The  pain  attending  these  cases  of 
Ltitestinal  obstruction  is  among  the  most  conspicuous 
and  most  constant  of  the  symptoms. 

It  is  usually  the  first  manifestation  of  the  attack. 

It   is  generally  at  the  commencement    of    great 

severity,  and  is  of  a  griping  or  colicky  character.     In 

several  instances  the  patients  are  spoken  of  as  being 

bent  double  with  the  pain,  or  even  as  rolling  on  the 

*  Med.  Times  and  Gazette^  vol.  i. ,  1872,  page  304. 


72  Intestinal  Obstruction,         [Chap.  iv. 

floor  ill  agony.     Often  it  appears  to  have  been  mode- 
rate, but  ill  no  case  could  it  be  described  as  trivial. 

As  to  the  situation  of  this  early  pain,  Mr.  Gay,  in 
his  well-known  essay  on  "The  Solitary  Band,"  observes, 
"  the  localisation  of  the  pain  is  ever  at  first  due  to  the 
constricting  agent,  and  marks  its  seat."  In  other 
works  similar  observations  occur.  With  these  state- 
ments I  might  be  permitted  to  disagree.  In  examin- 
ing into  the  clinical  history  of  the  fifty  cases  that  form 
the  basis  of  the  present  remarks,  I  find  that  in  many 
instances  the  initial  pain  was  distinctly  referred  to  a 
spot  that  subsequent  post-mortem  examination  proved 
to  have  corresponded  to  the  seat  of  obstruction.  But 
in  a  still  greater  number  of  the  cases  this  pain  is 
described  as  being  located  in  a  point  more  or  less  re- 
mote from  the  seat  of  strangulation.  The  proportion 
of  the  latter  class  of  case  to  the  former  is  nearly  that 
of  two  to  one.  Taking  all  the  cases  together,  it  is 
seen  that  in  the  majority  of  them  the  pain  is  referred 
to  the  immediate  vicinity  of  the  umbilicus.  In  some 
of  these  examples  the  obstructed  coil  was,  it  is  true, 
found  to  be  placed  near  to  the  umbilicus,  and  in  other 
cases  the  strangulating  band  had  an  attachment  close  to 
that  cicatrix.  But  in  still  other  and  more  numerous  in- 
stances the  situation  of  the  intestinal  lesion  was  found 
to  be  remote  from  the  umbilicus,  was  located  in  the 
right  iliac  fossa,  or  deep  in  the  pelvis,  or  close  to  a 
hernia]  opening  about  the  groin.  Still  more  marked 
examples  of  this  lack  of  relationship  may  be  given. 
A  few  of  them  are  the  following.  The  pain  was  on 
the  right  side  just  below  the  liver  ;  the  obstruction  was 
in  the  ileum  eighteen  inches  from  the  csecum.*  The 
pain  was  on  the  left  side,  and  on  a  level  with  the 
navel,  and  in  one  case  where  it  was  so  placed  a  coil  of 
ileum  had  passed  through  a  rent  in  the  right  broad 

*  Med.  Times  and  Gazette,  vol.  ii.,  1876,  jiage  651. 


Chap.  IV.]       Strangulation  by  Bands.  73 

ligament,'^  while  in  another  the  strangulation  was  deep 
in  the  right  iliac  fossa,  f  The  pain  was  near  the  gall 
bladder ;  the  obstruction  was  in  the  ileum.  \  The  pain 
was  in  the  epigastrium,  and  the  trouble  that  caused  it 
was  due  to  a  band  passing  between  the  urinary  bladder 
and  the  lumbar  spine. § 

In  speaking  of  the  situation  of  the  pain  in  intesti- 
nal obstruction  in  a  subsequent  chapter,  I  have  pointed 
out  the  physiological  improbability  that  a  painful  spot 
among  a  series  of  complicated  and  moving  coils,  like 
those  of  the  smaller  bowel,  would  be  accurately 
localised.  The  pain  in  intestinal  strangulation  would 
often  seem  to  be  a  referred  pain,  and  it  is  needless  to 
point  out  that  in  affections  of  other  abdominal  viscera, 
discomfort  is  often  felt  at  a  distant  point.  From  the 
frequency  with  which  the  pain  is  referred  to  the 
vicinity  of  the  umbilicus,  it  might  be  gathered  that  it 
has  been  conducted  to  the  great  abdominal  nervous 
centres.  It  is  complained  of,  with  strange  frequency, 
as  being  about  the  middle  line.  The  solai'  plexus, 
through  which  the  small  intestine  is  supplied,  is 
situated  about  four  inches  above  the  umbilicus,  while 
the  superior  mesenteric  plexus  commences  still  nearer 
to  the  navel,  and  runs  for  some  little  distance  almost 
directly  in  the  middle  line.  Pain  conducted  along  the 
latter  plexus  would  probably  be  most  definitely  felt 
near  the  middle  line,  and  about  the  umbilicus.  It  may 
be  noted  that  the  pain  to  which  reference  is  now  being 
made  is  a  pain  due  to  compression  of  a  limited  part  of 
the  gut,  and  not  one  depending  upon  disordered  peri- 
staltic movement.  The  pain  caused  by  such  move- 
ments could  not  well  be  localised,  since  its  very  occur- 
rence involves  a  constant  changing  of  position.    From 

*Path.  Soc.  Trans.,  vol.  xii,,  page  103. 

t  Union  Medicale,  1860,  page  97. 

t  British  Med.  Journ.,  vol.  i.,  1883,  page  999. 

^BuU.  de  la  Soc.  Anat.,  1843. 


74  Intestinal  Obstruction.        [Chap,  i v. 

the  facts  themselves,  however,  I  would  maiiitain  that 
the  position  of  the  pain,  in  this  form  of  internal 
strangulation  is  of  no  diagnostic  value  as  a  guide  to 
the  seat  of  the  lesion  ;  that  it  is  more  often  complained 
of  about  the  umbilicus  than  elsewhere,  and  that  as  a 
means  of  ascertaining  the  locality  of  the  trouble  it  is 
actually  misleading. 

The  pain  that  is  so  conspicuous  a  feature  at  the 
commencement  of  these  cases  persists  throughout  the 
course  of  them.  It  does  not,  however,  retain  its 
original  intensity.  It  soon  becomes  less  severe,  and 
often  undergoes  considerable  abatement.  In  some  of 
the  more  acute  cases,  however,  it  has  persisted  with 
all  its  original  intensity  until  deadened  by  the  col- 
lajDse  that  supervenes. 

The  pain  often  ceases  shortly  before  death.  This 
circumstance,  however,  is  of  no  significance ;  it  is 
usually  coincident  with  a  profounder  collapse,  or  with 
gangrene  of  the  bowel  involved,  or  with  advanced 
narcotism. 

One  or  two  cases  have  been  recorded  where  the 
pain  has  been  almost  an  insignificant  feature,  and 
of  these  extremely  rare  cases  no  satisfactory  explana- 
tion can  be  given.  The  most  striking  one  that  I 
have  met  with  is  reported  by  Mr.  Hulke."*  The 
patient  was  a  man,  aged  thirty-two,  who,  after  a 
hearty  meal,  was  seized  with  sudden  abdominal  pain 
and  vomiting.  The  pain  soon  passed  ofif,  but  the 
vomiting  persisted  and  became  very  severe.  Neither 
faeces  nor  flatus  were  passed  by  the  rectum.  On  the 
tenth  day  the  vomiting  was  feculent,  but  the  patient 
still  complained  of  little  or  no  pain.  Such  pain  as 
there  was  was  about  the  umbilicus.  Laparotomy  was 
performed,  and  the  man  survived  the  operation  fifty- 
three  hours.  The  autopsy  revealed  a  coil  of  the 
lower  ileum  strangulated  beneath  a  band  formed  by 
*  Medical  Times  and  Gazette,  vol.  ii.,  1877,  page  482. 


Chap.  IV.]       Strangulation  BY  Bands.  75 

an  epiploic  appendix  of  the  sigmoid  flexure  that  had 
become  adherent  to  the  peritoneum  near  the  right 
sciatic  notch. 

The  pain  in  the  hernia-like  strangulation  of  the 
bowel  is  continuous.  It  presents  slight  exacerbations, 
as  do  all  "  colicky "  pains.  It  does  not,  however, 
intermit  at  any  time,  nor  are  there  any  intervals  of 
calm  between  definite  paroxysms. 

I  shall  later  on  have  occasion  to  draw  attention 
to  the  fact  that,  speaking  generally,  paroxysmal  pains 
indicate  an  incomplete  occlusion  of  the  bowel."^ 
When  the  obstruction  is  absolute  the  pain  becomes 
practically  continuous.  In  the  present  form  of  in- 
carceration the  lumen  of  the  gut  becomes  entirely 
obliterated,  and  the  pain  in  consequence  presents  no 
paroxysmal  character.  To  this  statement  there  are 
but  few  exceptions  to  be  made,  and  such  as  there  are 
are  probably  susceptible  of  explanation.  In  Mr. 
Gay's  monograph,  already  quoted,  he  states  that  he 
met  with  only  six  examples  of  paroxysmal  pain 
among  forty-one  cases  where  the  nature  of  the  pain 
was  indicated.  Among  my  fifty  cases  I  find  eight 
instances  of  intermittent  pain.  The  circumstances  of 
these  eight  examples  are  worthy  of  brief  notice. 

1.  Female,  aged  53.  Pain  appears  to  have  been  only 
paroxysmal  at  the  commencement.  Case  of  strangailation 
beneath  a  band ;  laparotomy  with  cure  on  sixth  day.t 

2.  Female,  aged  23.  Here  only  a  single  fine  of  gut  was 
found  beneath  a  band,  not  a  knuckle  or  loop  ;  the  obliteration 
of  the  canal  was  therefore  apparently  incomplete.  The  pain 
is  merely  said  to  have  "  persisted  on  and  off." J 

3.  Female,  aged  26.  Case  of  strangulation  beneath  a  band. 
Here  the  strangulation  does  not  appear  to  have  been  severe 
at  fii'st,  and  laparotomy  was  not  considered  necessary  until 
the  eleventh  day.§ 

*  See  chapter  xx. 

t  British  Medical  Journal,  1883,  page  999. 

X  St.  Bart.'s  Hosp.  Reports,  vol.  xvii,,  page  277. 

§  Bull,  et  Mem.  de  la  Soc.  do  Chir.  de  Paris,  1879,  page  632. 


76  Intestinal  Obstruction.        [Chap.  iv. 

4.  Female,  aged  21.  Strangulation  beneath  a  band.  The 
incarceration  was  not  severe,  and  when  laparotomy  vras  per- 
formed on  the  fourth  day  the  involved  coil  was  found  in 
good  condition.     The  patient  recovered.* 

5.  Male,  aged  42.  In  this  case,  already  alluded  to,  there 
was,  besides  the  incarceration,  a  strictui-e  of  the  intestine,  to 
which  the  paroxysmal  pain  was  probably  to  no  small  degree 
due. 

6.  "  A  boy."     Case  of  strangulation  beneath  a  band.f 

7.  Female,  aged  26.  Mr,  Bryant's  case  of  band  arising  from 
the  bladder.  Each  paroxysm  was  attended  with  stranguary, 
and  the  "  play "  allowed  to  the  band  by  its  mobile  point  of 
attachment  probably  prevented  the  obstruction  from  being  very 
complete. 

8.  Female,  aged  45.  Paroxysms  every  half -hour.  Two 
bands  were  found  to  hold  down  two  portions  of  bowel. 
Neither  band  compressed  the  gut  greatly,  and  the  upper  of  the 
two  involved  coils  was  but  veiy  slightly  pressed  upon  by  the 
band.  I 

In  the  majority  of  these  cases,  therefore,  there  is  some 
reason  to  suspect  that  the  occlusion  of  the  bowel  was  not  so 
complete  as  it  may  have  been,  nor  so  perfect  as  it  commonly 
is. 

During  the  early  stages  of  the  malady,  before  any 
abdominal  tenderness  exists,  the  pain  is  often  described 
as  being  relieved  by  pressure. 

There  is  a  direct  connection,  more  or  less  con- 
stantly observed,  between  the  severity  of  the  pain 
and  the  urgency  of  the  vomiting,  and  especially  be- 
tween the  pain  and  the  degree  of  constitutional 
disturbance. 

Tenderness  of  the  abdomen.— This  symp- 
tom, as  demonstrated  by  pressure  upon  the  abdomen, 
is,  as  a  rule,  entirely  absent  at  first.  It  may  never 
appear,  especially  in  cases  pursuing  a  rapid  course. 
In  a  few  cases  of  a  less  acute  character  it  has  been  of 
trifling  degree,  or  not  sufficiently  marked  to  attract 

*  Bull  et  Mem.  de  la  See.  de  Chir.  de  Paris,  1879,  page  .564. 
t  Sur  le  Diagnostic  et  Traitement  des  Etranglement  Internes. 
Thfese  de  Paris,  1870. 

X  Lancet^  vol.  ii.,  1873,  page  773. 


Chap.  IV]       Strangulation  BY  Bands.  77 

notice.  In  the  majority  of  cases,  however,  some  part 
of  the  abdomen  becomes  tender  during  the  course  of 
the  disease.  This  tenderness  may  be  limited  in 
extent,  or  diffused.  Limited  tenderness  usually  ap- 
pears about  the  second  or  third  day.  It  is  a  symp- 
tom that,  when  well  marked,  is  of  considerable 
diagnostic  value,  since  it  appears  to  be  always 
restricted  to  the  actual  seat  of  the  lesion.  It  depends, 
no  doubt,  upon  congestion  or  inflammation  of  the  in- 
volved coils,  or  upon  some  slight  peritonitis  excited 
in  their  serous  coat.  As  a  factor  in  diagnosis,  there- 
fore, it  is  of  much  more  value  than  is  the  simple 
spontaneous  pain  always  observed  in  these  maladies. 

A  diffused  tenderness  of  a  marked  nature  indi- 
cates the  onset  of  a  peritonitis,  and  is  also  a  symptom 
of  much  clinical  value.  When  peritoneal  inflam- 
mation has  become  diffused  a  general  tenderness  is 
practically  constant,  unless  modified  or  concealed  by 
profound  collapse  or  narcotism. 

In  several  cases,  after  the  symptoms  have  lasted  for 
a  few  days  and  the  pain  has  been  severe,  the  abdo- 
men has  exhibited  a  general  but  slightly  marked 
tenderness  on  pressure.  This  is  probably  the  result 
of  violent  peristaltic  movements.  In  such  move- 
ments the  muscular  coat  of  the  bowel  is  practically  in 
a  state  of  cramp,  and  there  is  no  reason  why  the  in- 
volved gut  should  not  become  as  tender  after  a  pro- 
longed attack  of  cramp  as  does  the  calf  of  the  leg 
after  it  has  been  the  seat  of  a  like  disturbance.  This 
cause  of  tenderness  may  perhaps  contribute  to  the 
production  of  the  local  "  \)wii  on  pressure,"  but  I 
presume  that  it  would  in  no  ordinary  case  attain  to 
the  marked  character  of  the  tenderness  due  to  perito- 
nitis. It  is  obvious  that  any  fine  distinctions  on  this 
Bcore  are  impossible. 

In  several  cases  of  localised  tenderness  pressure 
over  the  affected  spot  has  caused  an  increase  in  the 


78  Intestinal  Obstruction.        [Chap.  iv. 

colicky  pains,  and  has  induced  an  immediate  attack 
of  vomiting. 

Toiiiitiiig. — Vomiting  is  a  conspicuous  and  con- 
stant symptom.  In  an  isolated  case  or  so  it  has  been 
the  earliest  manifestation  of  the  obstruction.  In  the 
great  majority  of  cases  it  comes  on  immediately  after 
the  appearance  of  the  pain  or  within  a  few  hours  of 
that  event.  I  have  met  with  two  instances  where  the 
vomiting  did  not  appear  until  twenty-four  hours  after 
the  onset  of  the  pain.*  It  soon,  however,  became 
stercoraceous,  and  the  patient  died  on  the  eighth  day 
in  one  case,  and  was  cured  by  laparotomy  on  the  fifth 
day  in  the  other.  In  both  instances  the  initial  pain 
had  been  sudden  and  severe. 

As  regards  its  character  the  ejected  material  con- 
sists jBrst  of  the  contents  of  the  stomach  and  then 
usually  of  bilious  matters.  In  its  next  stage  it  may 
be  thin  and  of  a  brownish  colour,  or  be  comparable  to 
pea-soup,  or  be  of  a  yellow  tint  like  the  yolk  of  egg. 
Vomited  matters  with  these  characters  are  often 
described  as  possessing  an  "  intestinal  odour."  Lastly, 
the  vomit  may  become  stercoraceous. 

Stercoraceous  vomit  is  common  in  this  form  of 
obstruction.  In  five  of  my  fifty  cases  the  character  of 
the  ejecta  is  not  clearly  described,  but  in  the  remaining 
forty-five  cases  the  vomit  became  stercoraceous  in 
twenty-eight  instances,  and  remained  non-stercoraceous 
in  seventeen.  These  figures  very  closely  correspond 
with  those  given  by  Mr.  Gay.  That  surgeon  found 
that  the  vomited  material  became  stercoraceous  in 
twenty-six  cases  out  of  thirty-seven. 

The  period  in  the  attack  at  which  the  vomit 
assumed  a  feculent  character  varied  from  the 
second  to   the   ninth  day.     An  average  taken  from 

*  Dr.  Hilton  Fagge  ;  Guy's  Hosp.  Reports,  vol.  xiv.  :  Dr. 
Bocckel ;  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  tome  vi.,  1880, 
page  339. 


Chap.  IV.]        Strangulation  BY  Bands.  79 

the  twenty-eight  cases  gave  the  fifth  clay  as  the 
mean. 

An  examination  of  the  seventeen  cases  where  the 
vomit  remained  non-feculent  revealed  a  striking  fact. 
The  cases  separated  into  two  categories :  in  one,  death 
had  taken  place  before  the  usual  period  for  the  onset  of 
stercoraceous  vomiting  had  been  reached  ;  in  the  other, 
the  course  of  the  attack  had  been  less  acute  than 
usual,  and  the  patient's  life  prolonged  beyond  the 
average  duration.  Thus  feculent  vomiting  was  absent 
in  some  of  the  most  acute  and  in  some  of  the  least  acute 
cases.  In  nine  of  the  seventeen  examples  the  patient 
had  died  within  two  and  a  half  days  of  the  commence- 
ment of  the  attack.  In  the  remaining  eight  cases  life 
had  been  prolonged  on  an  average  to  the  eighth  day. 
In  one  instance  the  patient  had  died  on  the  fourth 
day,  but  the  matters  vomited  had  not  become  sterco- 
raceous. On  an  average,  life  was  prolonged  for  three 
days  after  the  onset  of  feculent  vomiting. 

Cazin  observes  that  stercoraceous  vomit  is  rare  in 
cases  of  strangulation  by  the  diverticulum.  This  is, 
to  a  certain  extent,  true,  since  these  cases  very  com- 
monly assume  a  rapid  course,  and  end  in  death  before 
the  usual  time  for  the  occurrence  of  such  vomiting  has 
been  reached. 

I  have  only  met  with  one  instance  where  the 
vomit  distinctly  contained  blood.  It  was  in  a  case  of 
acute  strangulation  of  the  lower  ileum  by  a  diverticu- 
lum. The  patient  lived  two  and  a  half  days.  The 
vomited  matter  was  never  feculent."^ 

When  once  it  has  set  in  the  vomiting  will  persist 
until  the  termination  of  the  attack.  It  is  one  of  the 
most  distressing  of  the  symptoms.  Everything  swal- 
lowed is  immediately  ejected,  and  even  when  nothing 
is  taken    by  the    mouth  the  vomiting  will   continue 

*  British  Med.  Journal,  vol.  ii,,  1882,  page  785;  by  Dr.  J. 
Cockle. 


8o  INTESTINAL    OBSTRUCTION.  [Chap.  IV. 

incessantly.  Often  a  little  movement  or  a  little  pres- 
sure upon  the  abdomen  will  excite  an  attack.  When 
not  actually  sick  the  patient  will  commonly  complain 
of  a  most  distressing  nausea  and  will  be  troubled  by 
eructations  of  flatus.  It  is  worthy  of  note  that  the 
patient  is  in  no  way  relieved  by  the  attacks  of  vomit- 
ing, as  may  be  the  case  in  other  maladies  associated 
with  this  symptom,  and  as  is  sometimes  the  case  in 
other  forms  of  intestinal  obstruction. 

With  few  exceptions,  the  longer  the  obstruction 
lasts  the  more  violent  and  distressins:  do  the  attacks 
of  vomiting  become.  Sometimes  they  may  cease 
entirely  a  few  hours  before  death,  just  as  the  pain 
may  abate  under  the  same  circumstances.  In  other 
cases,  however,  there  has  been  a  sudden  and  profuse 
gush  of  vomit  either  just  before  death  or  in  the  act  of 
dying,  the  fluid  pouring,  without  effbi-t,  from  the 
mouth  and  throus^h  the  nostrils.  This  is  observed 
also  in  other  forms  of  obstruction  and  sometimes  in 
death  from  peritonitis. 

In  a  few  isolated  cases,  where  the  obstruction  does 
not  appear  to  have  been  very  complete  at  first,  the 
vomiting  has  undergone  distinct  abatement  after  the 
violent  attack  marking  the  onset  of  the  trouble  has 
passed  away. 

Opium  has  often  a  very  decided  effect  upon  the 
vomiting.  When  the  patient  is  well  under  the  in- 
fluence of  the  drug  the  symptoms  of  intestinal  ob- 
struction may  be  more  or  less  efiiciently  masked.  The 
pain  abates,  the  pulse  imj^roves,  the  amount  of  urine, 
if  lessened,  increases,  and  the  vomiting  becomes  less 
troublesome  or  ceases  for  a  while.  Under  the  in- 
fluence of  opium,  stercoraceous  vomiting  even  may 
cease,  and  on  the  reappearance  of  the  symptom  the 
ejected  matters  may  be  non-feculent.  This  is  well 
illustrated  by  a  case  recorded  by  JMr.  Berkeley  Hill. 
The  patient  was  a  child  aged  ten,  and  the  obstruction 


Chap,  iv.i        Strangulation  by  Bands.  8i 

was  due  to  strangulation  of  the  ileum  under  a  band. 
By  the  tliird  day  of  the  attack  the  vomiting  was 
severe  and  feculent.  Opium  was  given.  For  four 
hours  the  vomiting  ceased  entirely,  and  when  it  re- 
turned was  much  less  distressing,  was  less  frequent, 
and  was  non-stercoraceous.  Although  laparotomy 
was  not  performed  until  the  seventh  day  the  vomited 
matter  appears  never  to  have  again  become  feculent, 
except  on  one  occasion.'* 

In  this  and  like  cases  it  is  probable  that  the  drug 
stills  the  peristaltic  movement  of  the  intestine,  so  that 
what  is  ejected  is  merely  the  contents  of  the  stomach 
and  of  the  highest  part  of  the  smaller  bowel. 

Peritonitis,  presumedly  by  the  paralysing  effect  it 
has  upon  the  intestine,  seems  to  have  some  influence 
upon  the  production  of  feculent  vomiting. 

When  acute  peritonitis  sets  in  early  there  is  cer- 
tainly a  much  less  tendency  for  the  ejected  matter  to 
become  stercoraceous.  In  some  cases  this  has  been 
very  marked.  The  same  may  be  said,  perhaps,  of 
chronic  peritonitis.  In  one  case  where  acute  strangu- 
lation of  the  bowel  occurred  during  the  progress  of 
a  chronic  peritonitis,  the  vomiting,  although  severe, 
never  became  stercoraceous.  Yet  the  patient  lived 
six  days.! 

In  nearly  every  instance  the  act  of  vomiting  is 
associated  with  much  retching  and  distress.  In  one 
case,  however  (that  of  Mr.  Hulke's,  quoted  on 
page  74),  where  the  patient  had  little  or  no  pain,  the 
vomited  matter  appears  to  have  gushed  passively  from 
the  mouth  with  little  trouble  to  the  patient.  The 
vomiting  was  in  this  instance  copious,  and  in  time 
feculent. 

Constipation. — Constipation  is,  as  a  rule,  abso- 
lute from  the   first,  and  continuous.     Neither  faecal 

*  Lancet,  vol.  i. ,  1876,  page  773. 

t  Case  by  M.  Larguier  dea  Bancels,  loc.  cit.,  page  64, 

G— 12 


82  Intestinal  Obstruction.        tchap.  iv. 

matter  nor  flatus  is  passed  after  the  onset  of  the 
attack.  It  would  seem  as  if  all  the  bowel  below 
the  seat  of  the  obstruction  became  instantaneously 
paralysed,  since  it  would  be  absurd  to  assume  that  in 
every  case  the  colon  is  quite  empty  at  the  time  that 
the  strangulation  occurs. 

The  exceptions  to  this  condition  of  things  are  very 
rare.  In  two  or  three  instances  a  motion  has  been 
passed  during  or  immediately  after  the  occurrence 
of  the  initial  symptoms,  and  was  probably  derived 
from  the  intestine  below  the  site  of  the  strangulation. 
Enemata  administered  almost  at  any  time  after  the 
commencement  of  the  attack  may  possibly  bring  away 
scybala  from  the  colon,  and  in  one  case  such  scybala 
came  away  repeatedly.  Flatus  generated  in  the  large 
intestine  may  also  be  passed,  but  the  circumstance  is 
quite  exceptional. 

I  have  met  with  two  recorded  instances  where 
blood  is  said  to  have  been  passed.  In  one  case,  in  a 
man  aged  53,  a  coil  of  the  lower  ileum,  eighteen 
inches  in  length,  was  strangulated  beneath  a  band. 
The  patient  died,  after  laparotomy,  on  the  sixth  day. 
Constipation  was  absolute  throughout,  but  the  patient 
is  said  to  have  passed  a  little  blood.  It  is  not  stated 
if  the  man  had  piles.*  In  the  other  case  (the  case  by 
Mr.  Berkeley  Hill,  alluded  to  on  page  80)  enemata 
on  two  occasions  brought  away  scybala  and  blood. 
The  patient  was  a  child  aged  ten,  and  there  is  no 
evidence  to  show  that  the  blood  was  derived  from  the 
seat  of  strangulation.  It  may  have  been  produced 
accidentally  by  the  enema  tube.  At  autopsies  blood  is 
frequently  found  in  the  engaged  coil  and  in  the  intes- 
tine above  it,  but  not,  so  far  as  I  am  aware,  in  the 
bowel  below  the  obstruction. 

Out   of    my   fifty    cases,    I    have   met    with    six 

^Dr.  Fincliam ;  Med,  Times  and  Gazette,  vol.  ii.,  1876,  page 
Cil, 


Chap.  IV.]       Strangulation  by  Bands,  83 

instances  where  a  more  or  less  copious  motion  or  mo- 
tions passed  during  the  course  of  the  disease.  In  all 
instances  the  event  occurred  shortly  before  death.  In 
two  of  the  examples  the  stool  must  have  been  derived 
from  the  bowel  below  the  obstruction  (which  was 
found  to  be  complete  at  the  autopsy),  and  I  believe 
that  its  evacuation  was  coincident  with  the  appearance 
of  general  peritonitis.  In  both  of  these  cases  a  single 
stool  was  passed  on  the  day  before  death.  In  both 
there  had  been  absolute  obstruction  for  more  than 
seven  days.  In  both  the  peritonitis  was  very  recent, 
and  was  not  due  to  perforation.*  It  is  not  difficult  to 
imagine  that  the  onset  of  so  grave  a  change  as  general 
peritonitis  may  produce  such  effect  upon  the  abdomi- 
nal nervous  centres  as  to  excite  the  passive  bowel 
below  the  obstruction,  although  of  the  nature  of  that 
influence  we  may  have  no  knowledge.  The  four 
remaining  cases  are  more  intelligible,  and  in  each  of 
them  the  unusual  motion  may  have  come  from  the 
bowel  above  the  obstruction. 

In  two  there  was  perforation,  and  in  two  there  was 
volvulus.  The  first  of  these  cases,  in  a  man  aged  twenty- one, 
had  assumed  a  subacute  course,  the  patient  dpng  on  the 
thirteenth  day.  Constipation  had  heen  absolute  throughout, 
but  shortly  before  his  death  the  patient  passed  a  copious  black 
liquid  stool  into  the  bed.  The  autopsy  showed  that  eight 
inches  of  the  lower  ileum  had  become  strangulated  beneath  a 
band  passing  fi-om  the  transverse  colon  to  the  caecum.  An 
ulcer  of  the  stomach  was  found  to  have  perforated,  and  the 
reHef  thus  given  to  the  distended  bowel  had  allowed  the  incar- 
cerated knuckle  to  become  partly  withdrawn  from  under  the 
band.  In  fact,  the  obstruction  at  the  last  moment  had  ceased 
to  be  complete,  t 

In  the  second  case,  an  aperient  given  shortly  before  death 
led  to  some  greenish  loose  motions  being  passed.  The  obstruc- 
tion had  been  complete  for  nine  days.  The  autopsy  showed  a 
perforation  of  the  bowel  above  a  coil  of  ileum  engaged  beneath 

*  Maunoury.     These  de  Paris,  1819. 

t  Dr.  Hilton  Fagge ;  Guy's  Hospital  Eeports,  vol.  xiv.,  page 
«<2i 


84  Intestinal  Obstruction,        [Chap.  iv. 

a  band.     The  mecliaiiism  of  the  relief  was  probably  the  same 
in  this  case  as  in  the  preceding.  * 

In  the  two  remaining  cases,  although  the  gut  was  in  each 
instance  beneath  a  band,  yet  the  main  cause  of  the  obstruction 
was  a  volvulus  of  the  engaged  coil.  Without  the  volvulus  the 
obstruction  would  have  been  but  partial.  It  will  be  shown  in 
speaking  of  twist  of  the  small  intestine,  that  the  constipation 
in  such  cases  is  commonly  not  complete,  and  to  that  variety  of 
obstruction  these  two  examples  more  properly  belong.  In  one 
of  the  examples  the  patient,  a  man  aged  twenty-one,  lived 
forty-three  hours,  and  passed  two  liquid  motions  not  long 
before  death,  f  In  the  other  case,  that  of  a  child  aged  foui-, 
constipation  had  been  complete,  and  all  the  symptoms  of  in- 
carceration were  marked  up  to  the  foui'th  day,  when  a  dose  of 
croton  oil  produced  a  copious  evacuation.  The  child  lived 
until  the  tenth  day.;}; 

GENERAL    CONSTITUTIONAL    SYMPTOMS. 

Rig'or. — In  only  one  case  among  fifty  can  I  find 
any  mention  of  a  rigor  associated  with  the  appearance 
of  strangulation.  In  this  solitary  instance  there  can 
be  little  doubt  that  the  rigors  (for  the  patient  had 
several)  were  connected  with  a  circumscribed  perito- 
nitis which  was  developing  at  the  time  of  the  onset 
of  the  incarceration,  and  that  they  had  no  direct  con- 
nection with  the  strangulation.  § 

Prostration. — Usually  coincident  with  the  onset 
of  the  attack  the  patient  exhibits  evidences  of  gi'eat 
prostration,  and  in  severe  cases  this  soon  deepens  into 
profound  and  even  fatal  collapse. 

There  is  great  muscular  weakness,  the  face  is 
drawn  with  pain  and  has  an  aspect  of  horrible 
anxiety,  the  features  become  pinched,  the  eyes  sunken 
and  surrounded  by  bluish  rings,  and  the  voice  weak 

*  Bull,  de  la  See.  Anat.  de  Paris,  1861,  page  118 ;  by  M. 
Brichetau.  , 

t  M.  Le  Moyne ;  Contrib.  a  I'Etude  de  rOcclusion  Intestinale. 
These  de  Paris,  1878. 

4:  Dr.  Kemot;  Path.  See.  Trans.,  vol.  xv.,  page  101. 

§  M.  Terrier ;  Bull,  et  Mdm.  de  la  Soc.  de  Chir.  de  Paris,  1879, 
page  564f 


Chap.  IV.]        Strangulation  BY  Bands.  85 

and  muffled.  A  cold  sweat  breaks  out  upon  the  sur- 
face, and  in  extreme  cases  the  limbs  become  cyanosed 
and  the  complexion  livid.  The  patient  at  last  sinks, 
retaining  his  intelligence,  as  a  rule,  to  the  last. 

The  pulse  is  small,  often  becoming  thready,  as  in 
23eritonitis,  and  of  increased  frequency.  It  commonly 
rises  to  120,  130,  or  140.  It  may  become  much  modi- 
fied when  opium  is  freely  given. 

The  tempei'atiu'e  is  commonly  throughout  the 
whole  case  subnormal,  being  the  temperature  of 
collapse.  Even  when  peritonitis  sets  in  it  may  still 
remain  subnormal.  In  acute  cases  it  may  be  found 
to  sink  gradually,  almost  hour  by  hour,  as  the  symp- 
toms advance,  and  it  may  even  continue  to  sink  when 
peritonitis  has  set  in.  A  gradual  increase  in  the 
frequency  of  the  pulse  is  often  associated  with  this 
depression  of  the  bodily  heat.  As  a  rule,  however, 
the  occiuTence  of  acute  peritonitis  has  an  appreciable 
effect  upon  the  temperature,  provided  that  it  has  not 
been  set  up  by  perforation,  and  may  cause  it  to  rise 
from  below  normal  to  normal,  and  to  reach  99°  or  99 '6°, 
or  even  100°.  When  perforation  occurs  at  the  end  of 
a  case  of  intestinal  obstruction  a  profounder  state  of 
collapse  is  as  a  rule  at  once  induced,  and  upon  the 
sinking  temperature  the  inflammation  has  no  in- 
fluence. 

A  rise  of  temperature  above  the  normal  in  a  case 
of  acute  strangulation  of  the  bowel  may  be  said  to,  in 
all  cases,  indicate  the  appearance  of  peritonitis. 

The  respii'atiojis  are  increased  in  frequency, 
are  superficial,  and  are  often  of  a  supracostal  type. 
In  this  form  of  obstruction  the  embarrassment  to  the 
respiration  caused  by  intense  distension  of  the  abdo- 
men is  very  rarely  met  with. 

The  tongpiie  is  usually  coated,  being  at  first  white 
and  then  becoming  diy  and  brown.  It  exhibits,  how- 
ever, some  few  exceptions  to  this  rule,  as,  for  example, 


86  Intestinal  Obstruction.        [Chap.  iv. 

in  a  case  in  which  the  tongue  on  the  tenth  day  of  the 
symptoms  is  described  as  being  moist,  white,  and  but 
slightly  coated. 

There  is  usually  a  very  offensive  taste  in  the 
mouth,  especially  after  the  vomited  matters  have  be- 
come stercoraceous. 

Intense  thirst  is  usually  complained  of,  espe- 
cially in  cases  where  vomiting  has  been  very  profuse. 
In  one  or  two  instances  the  occurrence  of  hiccup 
throughout  the  progress  of  the  case  has  been  noted. 

Urine. — The  quantity  of  the  urine  is  very  com- 
monly diminished,  and  in  the  most  acute  cases  may 
be  entirely  suppressed,  the  bladder  being  found 
empty.  As  will  be  subsequently  explained  (chapter 
XX.),  the  effect  of  internal  strangulation  upon  the 
renal  excretion  is  brought  about  mainly  through  the 
nervous  symptom.  A  diminution,  therefore,  in  the 
amount  of  the  urine  is  most  marked  in  the  most  acute 
cases,  and  in  those  attended  by  intense  pain  and 
much  collapse.  In  many  instances  the  excretion  of 
the  urine  has  been  immediately  increased  on  the 
patient  coming  under  the  influence  of  opium.  The 
position  of  the  obstruction  in  the  small  intestine  has 
no  effect  upon  this  symptom.  It  may  be  absent 
when  the  strangulation  concerns  the  jejunum,  and 
present  when  it  involves  the  ileum.  The  significance 
of  this  symptom  is  more  fully  dealt  with  in  the  chap- 
ter just  alluded  to. 

In  only  two  cases  was  stranguary  noticed.  In 
one  of  these  the  obstructing  band  was  attached  to  the 
bladder.  In  the  other,  so  large  a  mass  of  empty  coils 
hung  down  into  the  pelvis  that  it  may  possibly  have 
pressed  upon  the  bladder.  The  patient  was  a  girl 
aged  ten,  and  the  mass  was  found,  during  life,  to 
press  upon  the  rectum. 

In  not  a  solitary  case  was  tenesmus  complained 
of. 


Chap.  IV.]        Strangulation  BY  Bands.  87 

In  a  single  instance  the  patient  became  delirious 
before  death.  He  was  a  young  man,  the  symptoms 
were  very  acute,  and  death  ensued  in  less  than  two 
days. 

In  three  cases  out  of  the  fifty  the  patients  suffered 
from  cramps.  In  two  of  these  the  cramps  were  com- 
plained of  in  the  lower  limbs,  in  the  remaining  case 
in  the  jaws  and  hands.  In  all  three  examples  the 
symptoms  of  strangulation  were  very  severe,  and  the 
progress  of  the  case  rapid.  The  subject  of  muscular 
spasm  in  connection  with  strangulation  of  the  bowel 
has  been  fully  investigated  by  M.  Berger."^  He  finds 
that  the  cramping  pains  are  usually  in  the  feet  and 
calves,  that  the  symptom  is  limited  to  cases  of  severe 
strangTilation,  and  is  most  common  in  adults.  He 
has  collected  fourteen  cases  where  this  feature  was 
noted.  Eleven  were  cases  of  strangulated  hernia, 
two  of  strangulation  by  a  band,  and  one  of  obstruc- 
tion by  a  diverticle. 

It  is  in  a  case  of  this  kind,  associated  with  cramps 
in  the  limbs,  attended  by  profound  collapse,  with  a 
cold  skin  and  cyanosed  extremities  that  the  mistake 
of  diagnosing  intestinal  obstruction  for  cholera  has 
occurred.  This  error  may  well  be  made  when  the 
strangulation  has  been  preceded  by  an  attack  of 
diarrhoea,  t 

There  is  a  case  reported  by  Dr.  Peacock  that  is,  I 
should  imagine,  unique.  It  concerns  a  man,  aged  sixty- 
five,  who  died  collapsed,  and  in  whose  abdomen  a  small 
knuckle  of  the  ileum  was  found  strangulated  by  a 
band.  The  involved  gut  was  gangTenous.  The 
patient  is  said  to  have  been  ill  six  days  with  constipa- 
tion, but  to  have  worked  up  to  the  morning  of  his 
death. 

*Bull.  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  vol.  ii.,  1876, 
page  698. 

t  Bee  case  by  M.  Le  Moyne,  loc.  cit. 


88  Intestinal  Obstruction.        [Chap.  iv. 

THE  CONDITION  OF  THE  ABDOMEN. 

The  abdominal  walls  remain  flaccid,  or  in 
their  normal  condition  until  such  time  as  local  ten- 
derness becomes  marked,  or  general  peritonitis  sets 
in,  or  distension  reaches  a  considerable  degree.  Even 
in  some  cases  where  peritonitis  was  found  after  death, 
the  parietes  appear  to  have  retained  their  normal  sup- 
pleness to  the  end. 

Meteorisni.— Distension  of  the  abdomen  is  in 
this  form  of  obstruction  comparatively  slight.  It 
usually  appears  about  the  third  day.  In  no  case 
could  it  be  spoken  of  as  excessive.  The  most  extreme 
instance  of  distension  of  which  I  find  a  record  was 
met  with  in  a  patient  who  was  attacked  with  stran- 
gulation of  the  bowel  when  suffering  from  chronic 
tubercular  peritonitis.  It  never  approaches  to  the 
excessive  degree  of  distension  met  with  in  cases  of 
volvulus  of  the  sigmoid  flexure.  It  appears  to  be 
least  marked  in  the  rapid  cases,  and  especially  in 
cases  attended  by  active  peristaltic  movements  in  the 
bowels  and  extreme  vomiting.  Meteorism  to  attain 
great  magnitude  requires  the  intestinal  walls  to  be 
paralysed,  and  the  presence  of  colicky  pains  serves  to 
indicate  that  that  paralysis  has  not  yet  supervened. 
Excessive  vomiting  also  must  tend  to  keep  the  intes- 
tine empty. 

When  peritonitis  sets  in  the  meteorism  undergoes 
a  considerable  increase. 

The  swelling  is  usually  first  noticed  in  the  epigas- 
tric and  umbilical  regions,  and  may  form  a  very 
distinct  elevation  of  the  parietes  in  those  districts. 
The  regions  of  the  colon  remain  flat,  the  meteorism 
being,  of  course,  limited  to  the  lesser  bowel.  When, 
however,  the  distension  has  reached  any  magnitude 
it  practically  occupies  the  entire  abdomen.  In  one  case 
there  was  very  visible  distension  of  the  transverse 


Chap.  IV.]        Strangulation  BY  Bands.  89 

colon,  but  in  this  instance  the  great  omentum  had 
been  much  dragged  upon.  The  connection  between 
these  two  circumstances  is  discussed  elsewhere  (chapter 
vi.). 

On  percussion  the  abdomen  is  found  to  be  equally 
resonant  all  over,  although  early  in  the  case  there 
may  be  less  marked  resonance  or  absence  of  resonance 
in  the  region  of  the  colon.  That  part  of  the  bowel 
must  soon,  however,  become  overlapped  by  the  dis- 
tended small  intestine. 

A  careful  examination  of  the  abdomen  toy 
palpation  usually  reveals  nothing,  and  a  digital  ex- 
ploration of  the  rectum  gives  equally  negative  results. 

There  are,  however,  some  remarkable  and  rare 
exceptions  to  these  latter  statements.  (1)  Some  local 
dullness  may  be  discovered  in  the  otherwise  tympanitic 
abdomen ;  (2)  a  tumour  or  swelling  may  be  detected 
through  the  parietes ;  and  (3)  something  may  be  re- 
vealed by  an  examination  of  the  rectum. 

It  may  be  conceived  that  a  localised  area  of  dull- 
ness on  percussion  may  possibly  be  due  to  one  of 
three  things  :  to  an  extravasation  into  the  peritoneal 
cavity  ;  to  large  coils  of  gut  involved  in  the  strangu- 
lation ;  or  to  the  empty  loops  of  bowel  that  may  lie 
below  the  point  of  obstruction.  With  regard  to  a 
definite  swelling  or  tumour,  it  will  be  reasonable  to 
conclude  that  it  could  depend  upon  the  second  only 
of  these  possible  causes.  It  must  be  no  matter  of 
surprise  that  both  these  phenomena  (the  dullness  on 
percussion  and  the  swelling)  are  very  rare.  Much 
effusion  of  fluid  in  the  peritoneal  cavity  is  very  un- 
common in  these  cases  and  has  not  the  least  tendency 
to  become  localised  in  any  way.  Extravasations  of 
blood  do  take  place,  but  never,  I  believe,  attain  such 
magnitude  as  to  be  the  cause  of  dullness  on  percus- 
sion. In  the  second  place  the  involved  bowel  is  often 
a  mere  knuckle,  and  is  very  commonly  found  against 


90  Intestinal  Obstruction.         [Chap.  iv. 

the  posterior  abdominal  wall  or  within  the  pelvis. 
In  any  case  it  is  very  apt  to  be  covered  over  by  the 
distended  coils  above  the  obstruction.  In  the  third 
place  the  empty  coils  of  intestine  below  the  site  of 
the  incarceration  are  found,  with  comparatively  few 
exceptions,  to  hang  down  into  the  pelvic  cavity,  and 
to  be  thus  removed  from  examination. 

(1)  Localised  dullness  on  2)e7'cussio7i,  and  (2)  a 
tumour  felt  through  the  parietes. — In  my  fifty  cases 
I  find  only  seven  examples  of  the  first  phenome- 
non and  four  of  the  second.  With  one  exception, 
the  dullness  was  localised  in  the  right  iliac  region, 
the  rest  of  the  abdomen  being  tympanitic.  In 
every  instance  it  corresponded  to  the  site  of  some 
tenderness  on  pressure.  In  one  case  it  was  due  to 
the  matting  together  of  the  ileum  and  caecum  by 
adhesions.  In  all  the  other  examples  it  was  caused 
by  the  engorged  coil  involved  in  the  strangulation. 
This  coil  was  always  large,  varying  from  eight  inches 
in  one  case  to  two  metres  in  another.  In  the  excep- 
tion above  alluded  to  the  patch  of  dullness  was  just 
to  the  right  of  the  right  rectus  muscle.  It  was 
caused  by  a  loop  of  strangulated  jejunum. 

The  tumour  detected  through  the  parieties  was 
in  each  case  caused  by  large  loops  of  the  intestine 
engorged  by  strangulation.  In  one  example  the 
incarcerated  coil  was  filled  with  blood.  In  three  cases 
the  swelling  was  felt  in  the  right  iliac  fossa.  In  the 
fourth  case  it  was  in  the  middle  line  and  extended 
from  near  the  navel  almost  to  the  pubes ;  it  was  not 
observed  until  after  the  general  distension  had  been  re- 
lieved by  the  trochar,  and  was  caused  by  a  large  coil  of 
bowel  strangulated  by  a  diverticulum  adherent  to  the 
umbilicus.  The  swelling  seems  to  have  been,  in  each 
example,  ill-defined,  dull,  tender,  and  about  the  size  of 
the  fist.  It  is  remarkable  that  in  every  instance  the 
mass  was  not  felt  until  towards  the  end  of  the  case. 


Chap,  v.]        Strangulation  BY  Bands.  91 

or  was  discovered  rather  towards  its  conclusion  than 
its  commencement. 

(3)  A  tumour  felt  through  the  rectum. — Although 
extensive  coils  of  empty  and  flaccid  intestine  are  often 
found  hanging  inertly  into  the  pelvis,  I  know  of  only 
one  instance  where  they  were  felt  during  life.  This 
occurred  in  Mr.  Hill's  case  already  quoted  (page  82). 
Here  a  soft  round  mass  was  felt  through  the  rectum, 
and  was  found  to  press  upon  its  anterior  wall. 

In  only  three  cases  out  of  fifty  were  any  coils  of 
intestine  visible  through  the  anterior  ahdoviiiuil 
parietes.  One  was  a  case  of  acute  obstruction 
associated  with  a  remarkable  paroxysmal  pain  and 
demanding  laparotomy  on  the  third  day.  The  other 
cases  pursued  a  chronic  course,  death  ensuing  on  the 
thirteenth  and  fourteenth  days  respectively.  The 
movement  of  the  intestinal  coils  were  visible  in  both 
of  these  examples,  in  the  former  case  on  the  tenth 
day,  in  the  latter  on  the  seventh.  One  of  the  patients 
is  described  as  being  much  emaciated. 

These  cases  form  but  a  feeble  exception  to  the  rule  " 
that  visible  peristaltic  movements  are  met  with  only 
in  cases  of  chronic  obstruction. 


CHAPTER    Y. 

STRANGULATION  BY  BANDS  OR  THROUGH  APERTURES 

COURSE  AND  PROGNOSIS. 

The  coiu^se  pursued  by  this  form  of  obstruction  is 
always  more  or  less  acute  and,  so  far  as  is  at  present 
known,  every  case,  unless  relieved,  ends  in  death. 

The  duration  of  any  given  case  depends,  I  think, 
neither  upon  the  age  of  the  patient  nor  the  situation 
of  the  obstruction  in  the  lesser  bowel,  but  upon  the 


92  Intestinal  Obstruction.  [Chap.  v. 

tightness  of  the  strangulation  and  the  amount  of 
bowel  involved.  The  most  rapidly  fatal  cases  are 
those  in  which  a  considerable  quantity  of  intestine  has 
been  severely  strangulated.  The  two  conditions  must  be 
combined  ;  for  in  some  of  the  least  acute  cases  large 
coils  have  been  found  to  have  been  involved,  but  only 
moderately  compressed.  As  a  solitary  factor,  the  rigour 
of  the  incarceration  is  the  most  important  in  bringing 
about  a  rapidly  fatal  termination.  The  larger  the  coil 
so  involved  the  more  severe  the  manifestations. 

A  sudden  onset  of  symptoms  need  not  mean  a 
very  rapid  course.  Some  of  the  examples  of  abrupt 
onset  sliow^  a  period  of  ten  to  thirteen  days  before  death 
ensued.  As  a  rule,  however,  the  more  gradual  the 
development  of  the  symptoms  the  longer  is  the 
probable  duration  of  the  case. 

Since  in  snaring  by  loops  or  knots  larger  coils  are, 
on  an  average,  involved  than  in  the  case  of  strangula- 
tion under  a  band,  it  follows  that  the  progress  of  the 
malady  is  more  rapid  in  the  former  variety  of 
strangulation  than  in  the  latter.  In  the  former  class 
of  case,  moreover,  the  incarceration  is  usually  more 
complete  and  more  rigorous.  Thus  the  average  dura- 
tion until  death,  in  a  case  of  strangulation  under  a 
band  or  through  an  aperture,  is  six  days.  The 
average  duration  in  a  case  of  snaring,  whether  by 
a  false  ligament  or  by  a  diverticle,  is  four  days. 
Some  of  the  most  acute  cases  led  to  death  in  ten, 
seventeen,  and  twenty-four  hours,  while  in  the  least 
severe  instances  life  was  prolonged  to  the  thirteentli, 
fourteenth,  and  fifteenth  day.  Opium,  if  given 
in  large  doses,  has,  as  already  stated,  a  considerable 
effect  upon,  the  progress  of  any  given  case.  Under 
its  use  the  pain  and  vomiting  have  greatly  diminished, 
the  pulse  has  improved,  the  temperature  has  risen, 
and  the  patient  has  been  placed  apparently  in  a  much 
more  favourable  condition. 


Chap,  v.]         Strangulation  by  Bands.  93 

Many  of  the  patients  die  simply  of  collapse,  others 
die  later  of  exhaustion  brought  al^out  l)y  the  intensity 
of  the  pain,  the  severe  vomiting,  etc. ;  others  die  of 
acute  peritonitis. 

Peritonitis  is  not  very  commonly  found  in  this 
form  of  strangulation  of  the  bowel.  It  is  met  with 
in  a  little  more  than  one  half  of  the  cases.  The  period 
of  its  onset  and  the  conditions  under  which  it  ap- 
pears vary  greatly.  It  has  been  recorded  as  present 
in  a  patient  who  died  in  seventeen  hours  after  the 
commencement  of  the  obstructive  attack,  while  it 
has  been  found  to  be  entirely  absent  in  another  case 
where  the  individual  lived  fourteen  days.  The  average 
time  for  its  appearance  is  about  the  fifth  day. 

Perforation  of  the  bowel  above  the  seat  of  obstruc- 
tion is  quite  nncommon,  and  would  not  appear  to 
occur  in  more  than  10  or  12  per  cent,  of  all  the  cases. 
It  has  caused  death  as  early  as  the  fifth  day. 

In  speculating  as  to  tlic  possibility  of  spon- 
taneous recovery  in  cases  of  this  form  of  strangula- 
tion of  the  bowel,  one  cannot  fail  to  note  that  patients 
who  have  ultimately  died  of  acute  obstruction  have 
sometimes  had  previous  attacks  that,  so  long  as  they 
lasted,  were  as  severe  as  the  final  one.  It  would  not  be 
unreasonable  to  assume  that  these  previous  disturbances 
were,  in  some  cases  at  least,  brought  about  by  the  same 
mechanism  that  caused  at  last  the  fatal  attack.  If  so, 
they  may  prove  to  be  instances  of  spontaneous  relief 
of  an  acute  obstruction.  Then,  again,  an  isolated  case 
or  so  has  been  recorded  where  patients  were  attacked 
with  symptoms  of  intestinal  incarceration  that  could 
not  be  diagnosed  from  like  attacks  known  to  be  due 
to  "  bands."  These  patients,  after  being  almost  in 
articulo  mortis,  after  vomiting  feculent  matter  for 
days,  after  presenting  the  phenomena  of  absolute 
obstruction,  have  at  last  recovered.  So  far  as  I  am 
aware,  no  autopsy  at  a  subsequent  date  has  made  clear 


94  Intestinal  Obstruction.         [Chap.  v. 

the  nature  of  such  cases,  and  therefore  that  they 
may  have  been  cases  of  strangulation  by  bands  must 
be  a  matter  of  pure  conjecture. 

In  the  face  of  instances  like  these  it  is  well  to 
observe  what  light  the  post-mortem  examination  of 
fatal  cases  can  throw  upon  this  question  of  spon- 
taneous relief.  There  is  not  the  least  reason  for 
supposing  that  the  bowel,  when  it  has  been  strangu- 
lated for  a  certain  length  of  time,  has  the  least  power 
of  removing  itself  from  the  constricting  agent.  What 
we  know  of  strangulated  hernia  would  support  this 
impression.  There  is  a  circumstance,  however,  under 
which  sjDontaneous  reduction  may  occur  in  cases  of 
incarceration  of  recent  standing.  It  is  when  a  loop  of 
gut  has  passed  beneath  a  band  and  has  then  become 
so  twisted  as  to  have  its  lumen  closed.  In  such  a 
case  sudden  and  severe  symptoms  may  appear  and 
yet  the  band  without  the  volvulus  may  not  suffice  to 
strangulate  the  gut.  As  the  muscular  vigour  of  the 
gut  becomes  impaired,  or  is  rendered  feebler  by  the 
action  of  opium,  it  is  possible  to  conceive  that  the 
volvulus  may  untwist  and  the  coil  escape  from  the 
band  that  never  held  it  other  than  slightly.  This 
may  be  the  explanation  of  some  of  the  "  previous 
attacks  "  noted  in  cases  of  fatal  strangulation. 

AVhen  the  strangulation  is  well  advanced  recovery 
by  this  means  must  be  practically  impossible.  I  have 
alluded  to  two  cases  where  the  involved  gut  was  found 
to  be  partially  reduced  after  death  ;  but  in  these  cases 
the  reduction  had  been  effected  by  the  sudden  relief  to 
distension  caused  by  a  perforation.  The  very  cause 
that  brought  the  relief  but  served  to  hasten  the 
appearance  of  death. 

One  possible  factor  in  spontaneous  recovery  may 
be  the  giving  way,  from  gangrene,  of  the  constricting 
band.  Post-mortem  examinations  afford  some  support 
to  any  theory  based  upon  this  circumstance.     Many 


Chap,  v.]         Strangulation-  bv  Bands.  95 

of  the  bands  that  cause  obstruction  are  very  thin,  and 
have  but  a  poor  blood  supply.  They  must  be  greatly 
compressed  when  they  produce  incarceration,  and  yet 
experience  shows  that  they  usually  outlive  the  too 
vascular  bowel.  There  are,  however,  cases  where  the 
patient  seems  to  have  been  very  near  a  prospect  of 
spontaneous  recovery  when  death  occurred.  Among 
these  are  the  following :  In  one  case  of  lapar- 
otomy performed  on  the  third  day  of  the  acuter 
symptoms,  the  band  on  being  handled  was  found 
to  be  so  slender  that  it  broke  as  it  was  being 
lifted  up."^  In  two  other  cases  a  diverticulum  that  had 
caused  obstruction  was  found  to  be  so  softened  that  it 
was  partly  torn  away  from  its  point  of  origin,  f  In 
another  case  of  laparotomy,  that  ended  in  cure,  the 
diverticulum  was  more  livid  than  the  gut  that  it  was 
compressing;  and  lastly,!  Dr.  Servier  quotes  an 
instance  where  the  constricting  band  was  gangrenous 
and  on  the  point  of  rupturing.  § 

In  connection  with  the  question  of  diverticula 
becoming  gangrenous,  it  must  be  borne  in  mind  that 
such  an  event  may,  instead  of  leading  to  cure,  lead  to 
death  by  perforation  should  the  gangrenous  part  of 
the  process  be  pervious.  Indeed,  the  tearing  away  of 
the  diverticle  has  caused  fatal  peritonitis,  and  Cazin 
notes  a  case  where,  througli  the  rent  so  formed,  some 
metallic  mercury  that  had  been  administered  found  its 
way  into  the  peritoneal  cavity. 

A  specimen  in  St.  Thomas's  Hospital  Museum  j| 
shows  another  possible  means  of  escape,  although  a 
very  remote  one.  The  specimen  consists  of  a  part  of 
the  small  intestine  of  a  dog,  around  a  knuckle  of  which 

*  Bull,  et  Mem.  de  la  Soc.  de  Cliir.  de  Paris,  1879,  page  564. 
+  Dr.  Hilton  Fagge,  loc.  cit. ;  and  Dr.  Wilks,  Path.  Soc.  Trans., 
vol.  xvi.,  page  126. 

t  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1881,  page  210. 
§  De  rOcclvision  Intestiuale,  page  -12.    Liege,  1871, 
II  No.  Q  7. 


96  Intestinal  Obstruction.        [Chap. vi. 

Mr.  Travel's  had,  during  life,  firmly  tied  a  ligature. 
The  animal  died  on  the  third  day.  The  ligatured  part 
had  separated  and  was  found  in  a  kind  of  cyst  formed 
by  lymph  from  the  peritoneum.  Into  this  cyst  the 
two  ends  of  the  bowel  opened  so  that  the  integrity  of 
the  tube  was  practically  restored.  It  is  conceivable 
that  such  a  circumstance  may  occur  in  a  young  human 
subject  when  only  a  small  knuckle  of  gut  or  a  part  of 
the  circumference  of  the  gut  is  very  tightly  strangu- 
lated. 

It  is  not  impossible  that  in  a  favourable  case  the 
canal  of  the  intestine  may  be  completed  after  ob- 
struction by  the  formation  of  a  "  fistula  bimucosa " 
such  as  has  been  formed  in  some  cases  of  strangulated 
hernia. 

From  the  above  speculations  the  conclusion  may 
safely  be  drawn,  that  while  spontaneous  relief  in  acute 
obstruction  may  not  be  impossible,  it  must  at  least  be 
excessively  rare. 


CHAPTER    YI. 

ANOMALOUS    FORMS    OF    OBSTRUCTION   DUE   TO    ISOLATED 
BANDS    AND    TO    ADHESIONS. 

Under  tins  headiiig  may  be  grouped  a  remarkable 
series  of  cases,  all  more  or  less  infrequent,  in  which 
an  obstruction  has  been  brought  about  by  means  of  an 
adherent  diverticulum,  or  by  an  isolated  band,  or  by 
more  extensive  adhesions,  but  where  the  mechanism 
of  the  occlusion  is  unlike  that  involved  in  the  class 
just  described. 

These  cases  are  united  by  a  common  pathological 
bond,  while  clinically  they  present  conspicuous  differ- 
ences.    Unlike  the  form  of  obstruction  just  discussed, 


Chap. VI.]    Strangulation  over  a  Band.  97 

they  involve  the  large  bowel  with  almost  as  great  a 
frequency  as  they  involve  the  small. 

These  anomalous  cases  may  be  classified  under  the 
following  headings  : 

1.  Strangulation  over  a  "band. 

2.  Gcclusion  brouglit  about  by  acute  "kinldng  due  to  traction 

upon  an  isolated  band  or  an  adherent  diverticulum. 

3.  Occlusion  effected  by  udliesiuns  which  retain  the  bowel 

in  a  bent  posiiion. 

4.  Obstruction  by  means  of  adhesions  that  compress  the  gut. 

5.  Obstruction  by  the  matting  toffcther  of  several  coils  of 

intestine. 

6.  Obstruction  by  changes  effected  in  the  intestinal  walls 

due  to  simple  traction. 

7.  Narrowing  of  the  bowel  from  shriiilctng  of  the  mesentery 

after  inflammation. 

1.  StraiigiilatioiA  over  a  band. — If  several 
coils  of  a  thin  indiarubber  J)ipe,  through  which  water 
was  flowing,  were  thrown  over  a  tightly  drawn  wire, 
the  lumen  of  the  tube  would  become  more  or  less 
completely  occluded  at  the  spot  where  the  wire  was 
crossed.  It  is  conceivable  that  a  similar  circumstance 
may  be  met  with  in  the  abdomen  when  a  long  loop  of 
intestine  is  thro^vn  across  a  more  or  less  rigid  band. 
Here  the  weight  of  the  dependent  loops  would  act  as 
a  compressing  agent,  and  the  interference  with  the 
circulation  in  the  mesenteric  vessels  would  induce  an 
engorgement  of  the  involved  bowel.  It  is  difficult, 
however,  to  understand  how  such  a  form  of  obstruction 
could  occur  in  the  living  subject  without  some 
arrangement  of  parts  that  would  permit  the  dependent 
coils  to  retain  their  position.  One  would  imagine 
that  a  little  vigorous  peristaltic  movement  would 
soon  overcome  the  occlusion,  on  the  one  hand,  and 
withdraw  the  intestine  from  its  abnoimal  situation,  on 
the  other ;  although  it  is  more  than  probable  that  the 
intestinal  contents  could  enter  the  involved  loop  with 
much  more  readiness  than  they  could  leave  it.  I  have 
H— 12 


98  Intestinal  Obstruction.         [Chap.  vi. 

found  records  of  four  cases  where  this  form  of  ob- 
struction seems  to  have  taken  phice,  and  in  one  only 
is  the  mechanism  of  the  occlusion  uncomplicated.  In 
the  simplest  case  a  diverticular  band  passed  from  the 
ileum  to  the  umbilicus,  and  over  it  a  coil  of  ileum 
from  two  to  three  feet  in  length  was  found  to  have 
been  flung  and  to  be  hanging  suspended.  This  coil 
was  intensely  congested,  and  numerous  extravasations 
had  taken  place  beneath  its  serous  coat.  Symptoms 
of  obstruction  appeared  suddenly  during  perfect  health, 
and  the  patient  only  lived  ten  hours.*  In  two  other 
instances  an  extensive  loop  of  the  lower  ileum 
had  passed  through  a  hole  in  the  omentum.  The 
loops  were  black  with  congestion,  and  were  hanging 
down  into  the  pelvis.  In  one  case  the  coil  was  fixed 
in  this  position  by  recent  adhesions.  In  neither  of 
the  cases  was  the  obstruction  effected  by  the  aperture 
itself,  the  gut  being  very  readily  withdrawn  at  the 
autopsy.  As  the  author  of  one  of  the  cases  (Dr.  Fagge) 
observes,  the  strangulation  was  not  due  to  the  narrow- 
ness of  the  aperture,  but  to  the  hanging  of  the  gait 
over  its  lower  edge.  In  both  cases  the  symptoms 
appeared  suddenly ;  in  both  acute  peritonitis  was 
found  at  the  post-mortem ;  in  both  the  patient  lived 
five  days.f  In  the  fourth  case  a  diverticulum  passed 
to  be  attached  to  the  umbilicus,  and  over  it  two  loops 
of  the  ileum,  black  with  congestion,  were  suspended. 
They  w^ere  found  to  be  twisted  upon  themselves,  and 
it  is  impossible  to  say  which  was  the  primary  and 
most  essential  j^henomenon,  the  volvulus  or  the  hang- 
ing of  the  gut  over  the  cord.  The  symptoms  appeared 
suddenly,  acute  peritonitis  set  in  on  the  sixth  day,  and 
the  patient  died  on  the  ninth.  \ 

*  De  rOcchision  Intestinale,  by  Dr.  Lusseau.     Paris,  1870. 
t  Bull,  de  la  Soc.  Anat.,  page   252;   Paris,   1864;    case  by 
M.  Besnicr.    And  Guj-'sHosp.  llcports,  vol.  xiv.;  Dr.  Hilton  Fagge. 
;  Path.  80c.  Trans.,  vol.  vii.,  page  205  ;  case  by  I\Ir.  AVurd. 


Chap.  VI.]  Acute  Kinking.  ^9 

In  a  drawing  of  a  case  of  strangulation  by  an 
adherent  diverticulum,  given  by  Bouvier,  it  would 
appear  as  if  this  form  of  obstruction  had  had  great 
influence  in  producing  the  fatal  result.* 

The  four  cases  all  occurred  in  males.  The  ages 
were  respectively  22,  45,  and  ^'b^  the  fourth  case  being 
met  with  in  "  a  boy." 

So  far  as  can  be  judged  from  these  few  cases,  the 
symptoms  resemble  those  of  hernia-like  strangulation, 
a  sudden  onset,  severe  pain,  excessive  vomiting  (be- 
coming stercoraceous  in  at  least  one  instance),  and 
absolute  constipation.  In  the  case  fatal  in  ten  hours 
there  was  diarrhoea  and  profound  collapse.  The  main 
points  of  difference  between  these  cases  and  those  of 
incarceration  under  a  band  would  appear  to  consist  in 
the  less  continuous  character  of  the  pain  and  in  the 
fact  that  the  symptoms  all  advance  with  varying 
intensity.  These  features  are  intelligible  in  the  light 
of  the  fact  that  the  obstruction  in  these  cases  must 
be  comparatively  incomplete,  while  the  interference 
with  the  blood  circulation  in  the  bowel  would  be 
of  a  character  to  excite  inordinate  peristaltic  move- 
ments. 

2.  Occlusion  by  acute  kiiLkiug  due  to 
traction, — In  these  cases  a  band  attached  to  the 
bowel  so  drags  upon  its  point  of  attachment  that  the 
gut  becomes  acutely  bent  at  this  spot,  and  is  ulti- 
mately occluded  by  a  process  akin  to  the  kinking  that 
may  close  an  indiarubber  tube  (Fig.  1 8).  This  condition 
is  usually  met  with  in  the  case  of  a  diverticulum  or 
diverticular  ligament  attached  to  the  umbilicus,  or  in 
instances  where  an  isolated  adhesion  is  connected  with 
the  ileum  on  the  one  hand  and  some  more  fixed  and 
distant  point  on  the  other.  The  shortness  of  the 
mesentery  of  the  lower  ileum  favours  the  formation  of 
a  kink  in  that  part  of  the  bowel. 

*Bull.  lie  rAcad.  de  Med.,  tome  xvi.,  page  083,  18-51. 


loo  Intestinal  Obstruction.         [Chap.  vi. 

Dr.  Reignier  has  shown  that  it  is  possible  for  an 
unattached  diverticle  to  cause  obstruction  by  kinking, 
if  the  process  become  much  distended.  He  found 
in  the  body  of  an  infant  a  free  diverticulum  7  centi- 
metres long.  On  injecting 
water  into  the  gut  above  the 
process,  he  found  that  when 
the  pressure  was  moderate  the 
diverticle  simply  became  filled 
and  that  the  fluid  passed 
readily  by  it.  When,  however, 
Fig.  18.  the    pressure    was    much    in- 

creased the  process  dilated 
enormously,  and  so  pressed  upon  the  gut  below  its  point 
of  origin  as  to  bend  the  intestine  tranversely  and  finally 
occlude  its  lumen. "^^  He  gi^'es  a  case  in  the  j^erson  of 
a  man,  aged  22,  that  illustrates  this  experiment  in 
practice.  This  patient  died  after  exhibiting  for  ten 
days  tlie  symptoms  of  acute  intestinal  obstruction.  The 
autopsy  showed  a  free  diverticulum  much  dilated  by 
liquid  faeces,  and  which  had  so  acutely  bent  the  gut 
from  w^hich  it  arose,  that  the  lumen  of  the  intestine 
M-as  quite  closed.  On  lifting  the  divei-ticle  and  gently 
pressing  it  the  obstruction  was  at  once  overcome. 

In  cases  of  kinking  by  adherent  diverticula  and 
bands  it  is  probable  that  distension  of  the  bowel  may 
be  active  in  brinirinj;  the  obstruction  about.  ^Moreover, 
distended  coils  of  intestine  may  press  upon  the  liga- 
ment itself  and  so  cause  it  to  be  stretched. 

The  following  are  examples  of  kinking  produced 
by  isolated  adhesions  :  In  a  case  by  Louis,  a  band 
was  found  to  pass  between  an  o\arian  cyst  and  the 
lower  ileum.  When  the  cyst  was  emptied  by  the 
trochar  the  band  was  stretched  and  so  dragged  upon 
the  bowel  that  it  was  closed,  and  symptoms  of  intes- 
tinal obstruction  developed.  Heller  reports  a  case 
*  Bull,  (le  la  Soc.  Anat.,  page  279.     Paris,  1879. 


Chap. VI.]  Acute  Kinking.  loi 

where  a  loop  of  the  lesser  bowel  was  adherent  to  a 
gravid  uterus.  After  delivery  the  traction  upon  the 
intestine  was  such  that  it  became  acutely  bent  and 
occluded.  "  Warren  saw  a  pedunculated  subperitoneal 
fibroid  of  the  uterus  so  wedged  in,  in  consequence  of  a 
sudden  change  of  position,  between  the  wall  of  the 
pelvis  and  a  false  ligament  stretched  from  the  lowest 
part  of  the  ileum  to  the  uterus,  that  the  former  was 
bent  and  occluded  by  the  traction  of  the  band  attached 
to  it."  *  Dr.  Hilton  Fagge  records  the  case  of  a  little 
girl,  aged  9,  in  whose  abdomen  at  the  autopsy  many 
old  adhesions  were  found  resulting  from  a  local 
peritonitis  set  up  by  caseous  degeneration  of  the 
mesenteric  glands.  Some  adhesions  passed  between 
the  sigmoid  flexure  and  the  ileum,  others  between  the 
latter  bowel  and  the  omentum  ;  while  the  mesentery 
was  so  much  shrunken  as  to  bind  the  small  intestine 
closer  to  the  spine.  The  immediate  cause  of  obstruction 
seems  to  have  been  due  to  a  band  that  fixed  the  small 
intestine  to  the  liver,  and  that  caused  great  angular 
bending  of  the  bowel.  At  this  bend  the  empty  and 
the  distended  coils  met,  while  above  that  point  was  a 
perforation  in  the  jejunum,  f 

One  of  the  best  examples  of  obstruction  by  kink- 
ing due  to  an  adherent  diverticle  is  given  by  Dr. 
Wilks.  The  process  in  this  case  was  attached  to  the 
umbilicus  and  had  been  so  stretched,  probably  by  the 
meteoristic  state  of  the  gut,  that  it  had  become  torn 
and  so  had  induced  peritonitis.  %  The  gut  was  normal  at 
the  seat  of  the  acute  bend,  as  indeed  it  appears  to 
have  been  in  all  the  cases  belonging  to  this  category. 
In  Dr.  Wilks'  case  the  dragging  of  the  empty  and 
pendulous  coils  below  the  attachment  of  the  diverticle 
appears  to  have  helped  in  maintaining  the  obstruction. 

*  Leichtenstern,  loc.  cit.,  page  530. 
tPath.  Soc.  Trans.,  vol.  xxvii.,  page  157. 
X  Ibid.,  vol.  xvi.,  page  126. 


102  Intestinal  Obstruction.         [Chap.  vi. 

Dr.  Quain*  reports  the  following  case  iii  a  woman 
aged  53:  A  large  perinephritic  abscess  had  been 
opened,  to  the  wall  of  which  the  descending  colon 
was  adherent.  The  patient  died  with  symptoms  of 
obstruction  lasting  twelve  days.  The  adlierent  colon 
was  found  to  have  been  so  bent  by  the  collapse  of  the 
al)scess  wall  as  to  have  become  occluded. 

So  far  as  can  be  judged  from  the  few  cases  pub- 
lished, the  sijmjjtoms  due  to  kinking  of  the  bowel 
are  very  nearly  identical  with  those  of  strangulation 
under  a  band. 

The  onset  is  usually  less  abrupt  and  the  progress 
of  the  case  less  acute,  patients  living  eleven,  fifteen, 
and  twenty  days  in  some  instances.  The  sym^Dtoms 
also  are  such  as  would  suggest  that  the  occlusion  is 
not  absolute.  Thus  the  pain,  although  severe,  will 
present  very  unequal  degrees  of  intensity  ;  the  -somit- 
ing,  although  often  incessant  and  distressing  and 
stercoraceous,  may  abate ;  the  meteorism,  even  in 
cases  of  long  duration,  may  be  quite  slight.  The 
constipation,  moreover,  although  usually  complete, 
may  yield  a  little,  and  the  bowels  be  0})ened  by  an 
aperient  even  when  the  symptoms  of  obstruction 
have  lasted  eight  days,  as  in  Dr.  Fagge's  case. 

3.  Occlusions  by  adhesions  that  retain 
the  boAvei  in  a  bent  position.— In  these  cases, 
which  concern  both  the  large  and  the  small  intestine, 
the  gut  is  found  to  have  become  adherent  to  some 
fixed  point  in  such  a  way  that  a  more  or  less  acute 
bend  is  produced.  The  site  of  the  adhesion  is  on 
the  abdominal  or  pelvic  parietes  or  the  pelvic 
viscera.  It  may  be  on  the  liver.  The  usual  cause  of 
the  adhesion  is  either  pelvic  peritonitis  or  hernia.  In 
the  case  of  the  rupture,  the  part  of  bowel  adherent 
is  the  same  that  occupied  the  hernia.  The  condition 
is  met  witli,  tlierefore,  only  after  enteroceles,  and  only 
"  I'atli.  Soc.  Trans.,  vol,  v.,  ^lage  179. 


Chap,  vi.i         Bending  of  the  Bowel.  103 

after  such  as  have  been  stranguhited  or  inflamed. 
The  })o\v('l,  presenting  in  any  case  some  inflammation 
of  its  serous  coat,  is  reduced  into  the  abdomen,  and 
instead  of  remaining  free  in  that  cavity,  contracts 
adhesions  by  means  of  its  inflamed  surface  with  some 
otlier  part  of  the  2)eritoneum. 

In  every  case  of  this  kind,  so  far  as  I  am  aware, 
the  adhesion  of  the  bowel  has  been  to  the  parietes 
in  the  vicinity  of  the  hernial  orifice. 

The  bowel,  having  been  recently  herniated,  usually 
acquires  an  adhesion  in  a  bent  position,  and  when 
so  fixed  often  leads  to  further  intestinal  troubles, 
in  cases  where  strangulated  or  inflamed  hernire  have 
been  successfully  reduced. 

The  condition  usually  occurs  after  femoral  ruptures, 
inasmuch  as  such  hernia?  are  peculiarly  prone  to 
become  incarcerated  or  inflamed,  while  the  com- 
paratively small  amount  of  gut  they  usually  contain 
favours  the  formation  of  these  particular  adliesions. 
Among  other,  and  less  frequent,  causes  of  these 
attachments  may  be  noticed  peritoneal  cancer,  and, 
so  far  as  attachments  to  the  liver  are  concerned,  the 
local  trouble  excited  by  gall  stones.  It  is  a  singular 
coincidence  that  pelvic  peritonitis,  femoral  hernia, 
peritoneal  cancer,  and  gall  stones  are  all  much  more 
common  in  women  than  in  men,  and  this  serves  to 
explain  the  fact  that  the  present  form  of  intestinal 
obstruction  is  practically  limited  to  females.  Out 
of  the  fifteen  cases  that  I  have  collected  there  is 
one  instance  only  in  a  male.  In  this  isolated  example 
the  adhesions  had  followed  upon  some  local  mischief 
excited  by  tapping  tlie  bladder  above  the  pubes.*  All 
the  cases  occurred  in  adults,  the  youngest  patient 
l)eing  a  woman  of  thirty  (pelvic  peritonitis),  the  oldest 
M  woman  of  fifty-nine  (omental  cancer). 

*  Dr.  Briddoii ;  Ncu-  York  Med.  Jour.,  vol.  xxxii.,  1SS2,  pasi-e 
UG. 


104  Intestinal  Obstruction.         [Chnp.  vi. 

The  involved  gut  is  usually  adherent  at  one 
isolated  spot  only,  and  a  single  and  simple  angular 
bend  is  thus  produced.  This  is  the  condition  met 
with  in  those  cases  that  depend  upon  hernia.  In 
other  instances  the  attachment  may  he  more  extensive, 
as  in  a  case  of  Dr.  Fagge's,  where  one  foot  of  the 
lower  ileum  was  found  adherent  to  the  anterior 
abdominal  parietes  as  a  result  of  omental  cancer. 
Moreover,  the  bends  formed  in  the  bowel  may  be 
by  no  means  simple.  There  may  be  several  angular 
bends,  the  loops  being  adherent  at  more  points  than 
one,  and  made  to  assume  the  outline  of  the  letter  \^* 
This  arrangement  may  be  still  further  complicated 
by  the  matting  together  of  the  three  bars  of  the 
intestinal  N,  whereby  the  false  position  is  perpetuated. 
In  one  case  where  N-like  bends  were  produced  only 
four  inches  of  bowel  were  involved,  so  that  the  angles 
formed  were  very  acute  and  abrupt,  f 

A  few  examples  may  be  given  to  illustrate  the 
varieties  assumed  l>y  this  form  of  intestinal  obstruc- 
tion. The  convexity  of  the  ascending  colon  may 
become  adherent  to  the  o\'ary,  and  the  gut  be  so 
narrowed  at  the  bend  as  barely  to  admit  a  crow-quill.  \ 
The  transverse  colon  may  become  adherent  to  the 
fundus  uteri.  §  The  rectum  may  attach  itself  to  a 
cancerous  ovary,  and  present  in  consequence  a  very 
angular  bend.  ||  The  sigmoid  flexure  may  adhere  to 
a  uterus  the  seat  of  a  malignant  disease,  and  present 
so  abrupt  a  bend  that  fatal  obstruction  with  symptoms 
like  those  of  volvulus  may  ensue.** 

*  Case  by  ^I.  Cossy,  quoted  by  M.  Nouet  ;  De  rOcchision 
Intestinale  dans  ses  Rapports  avec  les  Inflammations  pdri-uterines 
chroniques.     Paris,  1874. 

t  Louis  ;  Archiv.  Gen.  de  Med.,  l^^  Serie,  tom^e  xiv.,  page  193. 

i  Ducliaussoy,  M^m.  sur  I'Anat.  Path,  des  Etrang.  Internes, 
1860. 

^  Dr.  Hilton  Fagge,  loc.  cit. 

Ij  Path.  Boc.  Trans.,  vol.  xvi.,  page  197. 

**  M.  Cossy ;  i\I<'m.  de  la  Soc.  d'Observat,  185*),  tome  iii. 


Chap,  vi.j         Bending  of  the  Bowel.  105 

The  period  of  time  that  may  intervene  between 
the  formation  of  the  adhesion  and  the  occurrence 
of  symptoms  of  intestinal  obstruction  varies  greatly. 
In  the  case  following  aspiration  of  the  bladder  just 
alluded  to,  evidences  of  ol)struction  appeared  within  a 
few  days  of  the  original  lesion.  In  the  great  majority 
of  cases  the  intestinal  symptoms  do  not  make  their 
appearance  until  months  after  the  initial  peritonitis. 
I  think  tliat  in  the  cases  due  to  hernia  a  somewhat 
earlier  appearance  is  usual,  a  matter  in  most  instances 
of  weeks  rather  than  of  months.  Sometimes  years 
have  elapsed  between  the  causative  inflammation 
and  the  symptoms  of  obstruction,  such  examples 
being  most  usual  in  the  large  intestine.  Many  of  the 
patients  have  been  the  victims  of  chronic  constipation 
for  years  before  the  final  occlusion  occurred.  At  the 
same  time  it  must  be  noted  that  adhesions  of  the  same 
character  as  those  now  under  consideration  have  been 
met  with  in  the  autopsies  of  patients  who  presented 
no  marked  intestinal  symptoms  during  life. 

The  mechanism  of  the  obstruction  in  these  cases 
varies,  and  may  be  conveniently  considered  under 
three  categories,  taken  in  order  of  severity. 

1.  The  gut  at  the  adherent  point  may  become 
so  bent  that  occlusion  by  kinking  is  produced.  This 
is,  as  a  rule,  met  with  in  the  lowest  part  of  the  colon. 
The  symptoms  induced  are  severe  and  sudden  in  their 
onset.  Their  abrupt  development  possibly  depends  upon 
sudden  occlusion  at  the  bend,  brought  about  by  some 
distension  of  the  bowel,  or  some  change  in  its  position. 

2.  The  bowel  (a  portion  always  of  the  small 
intestine)  is  adherent  over  a  small  area,  and  symptoms 
of  obstruction  follow  from  certain  effects  of  traction 
without  conspicuous  occlusion  of  the  lumen  of  the 
tube.  It  is  certain  that,  so  far  as  the  lesser  bowel 
is  concerned,  mere  adhesion  over  a  limited  district 
tends  to  cause  an  impediment  to  the  passage  of  matter. 


io6  Intestinal  Obstruction.         [Chap.  vi. 

The  gut  at  the  adherent  spot  cannot  exercise  its 
peristaltic  function.  It  becomes  a  more  or  less  inert 
segment  in  an  active  tube.  If  a  little  acute  mischief 
be  excited  about  the  seat  of  the  adhesions,  symptoms 
of  an  acute  or  subacute  character  may  arise,  the 
exact  pathogenesis  of  which  is  a  little  obscure.  That 
form  of  rupture  known  as  Littre's  hernia  throws 
some  light  upon  these  cases.  In  this  hernia  the  gut 
is  tightly  held  down,  a  part  only  of  its  circumference 
is  nipjDed,  and  yet  symptoms  of  acute  mtestinal 
obstruction  follow,  the  greater  part  of  the  lumen 
of  the  bowel  being  at  the  time  often  quite  unoccluded. 
Supposing  a  patient  to  have  a  loop  of  intestine 
adherent  to  the  parietes,  and  that  some  little  inflam- 
matory trouble  is  excited  about  the  adherent  knuckle, 
it  would  seem  as  if  symptoms  of  subacute  obstruction 
could  arise  somewhat  upon  parallel  lines  to  those  that 
produce  the  manifestations  in  Littre's  hernia.  In  the 
case  following  asi:>iration  of  the  bladder  some  local  ]ieri- 
tonitis  kejit  up  after  the  gut  had  become  adherent  was 
apparently  suflicient  to  lead,  in  combination  with  the 
bent  bowel,  to  rather  acute  evidences  of  obstruction. 
In  other  instances  violent  peristaltic  movements,  such 
as  may  occur  during  colic  or  diarrhoea,  may  cause  a 
rough  dragging  upon  the  attached  intestine,  and 
so  add,  as  it  were,  the  fuse  to  a  train  already  laid 
and  prepared.  The  effect  of  a  little  local  peritonitis 
in  rendering  a  peritoneal  obstruction  an  actual  one 
is  often  illustrated.  As  one  example  I  might  cite  the 
following  :  An  old  man  was  admitted  into  the  London 
Hospital  under  the  care  of  my  colleague  Mr.  Rivington. 
The  patient  had  received  a  blow  upon  the  abdomen. 
A  few  days  after  admission  he  developed  symptoms 
of  acute  obstruction,  of  which  he  died  in  less  than  two 
days.  At  the  autopsy  the  transverse  colon  was 
found  to  be  bent  upon  itself  and  retained  in  that 
position  by  old  adhesions.     In  no  place  was  the  lumen 


Chap.  VI.]  Bending  of  the  Bowel.  107 

of  the  bowel  occluded.  The  peritoneum  was  healthy 
save  at  one  spot  over  the  liver  where  there  was  a 
little  local  peritonitis."^ 

As  regards  the  cases  now  under  notice,  it  can  only 
be  said  that  patients  may  die  of  more  or  less  acute 
obstruction,  and  exhibit  at  the  autopsy  an  adherent 
and  bent  intestine  about  which  some  little  peritoneal 
mischief  is  evident,  while  the  lumen  of  the  bowel  is 
at  no  point  wholly  or  even  nearly  occluded. 

3.  The  adherent  bowel  may  offer  a  more  or  less 
definite  mechanical  obstacle  to  the  passage  of  its 
contents.  A  part  of  the  colon  may  present  so  sharp 
and  rigid  a  bend  as  to  give  to  the  involved  intestine 
the  properties  of  a  stricture.  This  condition  is  well 
illustrated  by  a  case  reported  by  Dr.  Owen  Eees, 
where  the  rectum  was  so  involved.!  In  other 
instances  the  bowel,  and  particularly  the  lesser  bowel, 
is  adherent  over  a  wide  area,  and  the  mere  inertness 
of  the  attached  portion  constitutes  an  obstruction. 
This  is  well  seen  in  those  cases  Avhere  the  bowel  is 
adherent,' in  a  contorted  position,  as  when  it  assumes 
an  N-like  outline  and  the  limbs  of  the  N  are  bound 
together,  or  when  sevei-al  inches  of  it  are  blended  in  a 
straight  line  with  the  parietes,  as  in  Dr.  Fagge's  case 
quoted  above.  Here  the  bowel  above  the  diseased  part 
has  not  only  to  pass  its  own  contents  along,  but  has 
to  force  them  also  through  \h^  inert  and  adherent 
segment.  The  longer  this  segment  the  more  marked 
the  obstruction.  When  closely  bound  down,  the 
involved  gut  must  be  practically  incapable  of  peri- 
staltic movement,  and  must  be  to  the  rest  of  the  bowel 
as  a  piece  of  thin  indiarubber  tubing.  Pathological 
reports  and  museum  specimens  well  illustrate  this. 
The  adherent  bowel  is  either  of  normal  aspect  or  is 
abnormally  thin,  while  the  intestine  above  it  shows  a 

*ror  an  account  of  this  case  see  par.  5  of  this  chapter. 
\Mcd.  Times  and  Gazette,  vol,  i.,  1869,  page  436. 


io8  Intestinal  Obstruction.         [Chap.  vi. 

hypertrophy  of  its  walls  that  may,  in  some  instances, 
be  extreme."^  The  gut,  moreover,  just  above  the 
inert  part  often  shows  some  ulceration  of  the  mucous 
membrane,  due  presumedly  to  the  imtation  of  accumu- 
lated matters.  The  hypertrophy  is  all  in  the  muscular 
coat  and  compares  conspicuously  with  the  thin  walls 
of  the  inert  and  adherent  segment.  Moreover,  when 
there  is  much  angular  bending  of  the  gut  the  contents 
of  the  bowel  have  to  be  not  only  forced  through  an 
inert  tube,  but  have  to  take  a  devious  course  and 
encounter  certain  definite  obstructions. 

The  symptoms  associated  with  this  form  of  ob- 
struction will  obviously  show  great  variation.  They 
may  assume  an  acute,  or  a  subacute  or  a  chronic 
aspect,  and  may  differ  somewhat,  according  to  whether 
the  occlusion  is  situate  in  the  larcre  or  the  small 
intestine. 

A.  In  the  colon. — If  the  obstruction  be  due  to  a 
sudden  closure  of  the  gut  by  kinking  at  the  already 
bent  and  adherent  part  the  symptoms  may  be  of  a 
very  acute  character.  This  condition  appears  to 
most  usually  occur  in  connection  with  the  sigmoid 
flexure  or  rectum,  and  the  manifestations  produced 
are  identical  with  and  cannot  be  distinguished  from 
volvulus  of  the  former  segment  of  the  bowel.  I 
might  give  one  illustration.  A  woman,  aged  forty-four, 
was  admitted  into  the  London  Hospital  under  my  care 
suffering  from  symptoms  of  acute  obstruction.  These 
symptoms  had  appeared  suddenly  after  taking  an 
aperient.  They  were  precisely  the  symptoms  of 
volvulus  of  the  sigmoid  flexure.  The  patient  had 
been  the  subject  of  some  constipation  for  years,  and 
had  had  attacks  of  colic  occasionally.  In  twenty- four 
hours  after  the  onset  the  woman  was  in  a  precarious 
condition.  I  performed  laparotomy,  but  she  died  twelve 
hours  afterwards.  The  rectum  was  adherent  to  one 
*  See  case  by  Louis  quoted  above. 


Chap.  Vi.]  Sending  of  the  Bowel.  109 

point  of  the  pelvic  wall  in  a  bent  position.  The  bend 
here  had  become  so  extreme  that  the  gut  was  entirely 
occluded.  The  colon  above  was  enormously  distended, 
and  the  sigmoid  flexure  reached  to  the  right  of  and 
above  the  umbilicus.  On  emptying  the  colon  by 
puncture,  and  breaking  through  the  adhesions,  the 
passage  in  the  bowel  was  soon  restored.  The  cause  of 
the  adhesion  w^as  a  trifling  stricture,  which  had  helped 
to  make  the  sudden  closure  by  kinking  more  complete. 

The  symptoms  may  be  subacute,  as  in  a  case 
reported  by  M.  Cossy,  where  the  sigmoid  flexure  was 
adherent  to  a  cancerous  ovary.  Here  the  final  attack 
lasted  some  eight  or  nine  days,  and  was  marked  by 
paroxysmal  pain  with  idsible  peristalsis,  by  slight  non- 
stercoraceous  vomiting,  and  by  constipation  reKeved 
by  an  occasional  stool.  In  other  instances  the  mani- 
festations may  be  quite  chronic,  and  may  resemble  in 
all  points  those  due  to  stricture  of  the  rectum.  A 
case  of  this  character  has  been  reported  by  Mr.  Heath. 
He  performed  lumbar  colotomy  on  the  twentieth  day 
of  the  constipation.  The  rectum  was  adherent  to  the 
uterus  and  ovary  (which  was  the  seat  of  cancer),  and 
was  bent  into  a  sharp  sigmoid  form."* 

B.  In  the  small  intestine. — The  symptoms  when 
the  obstruction  is  in  this  part  of  the  bowel  may  be 
acute  or  chronic.  A  more  or  less  typical  example  of 
each  form  may  be  given.  I  saw,  in  consultation  with 
Dr.  Towne  of  Kingsland,  a  woman,  aged  58,  who 
three  months  previously  had  had  some  inflammation 
about  a  small  femoral  hernia.  The  bowel  was  reduced 
at  the  time,  and,  to  her  surprise,  had  never  come  down 
again,  nor  given  her  any  trouble.  She  was,  when 
seen,  sufiering  from  intestinal  obstruction;  the  onset 
had  not  been  sudden.  She  had  much  pain  of  a 
markedly  paroxysmal  character.  She  vomited  at  first 
at  long  intervals,  bringing  up  large  quantities  of 
*Patli.  Soc,  Trans.,  vol.  xvi.,  page  197. 


i  I O  InTES  TINA  L    ObS  TR  UC TION.  [Chap.  VI . 

matter.  As  the  case  progressed  the  vomiting  became 
more  frequent  (every  two  or  three  hours)  and 
feculent.  She  had  constipation  that  was  absolute  but 
for  one  slight  liquid  motion  passed  during  the  first  few 
days  of  the  attack.  I  performed  laparotomy  on  the 
seventh  day,  and  found  a  coil  of  greatly  distended  ileum 
adherent  in  a  bent  position  to  the  vicinity  of  the 
femoral  ring.  The  adhesions  retaining  it  were  readily 
broken  down  and  the  abdomen  then  closed.  She 
never  vomited  after  the  operation;  a  very  copious 
motion  was  passed  on  the  fourth  day  and  the  patient 
made  a  perfect  recovery. 

In  Dr.  Fagge's  case,  quoted  above,  where  a  foot  of 
the  ileum  was  adherent  to  the  parietes,  the  symptoms 
lasted  some  five  months.  There  was  constipation  that 
alternated  with  diarrhoea,  vomiting  that  appeared  late 
in  the  case,  and  that  came  on  once  or  twice  in  the 
twenty-four  hours,  the  patient  bringing  up  immense 
quantities  each  time,  and  pain  of  a  very  marked 
paroxysmal  character.  There  was  a  dragging  pain 
about  the  lower  part  of  the  abdomen.  The  vomited 
matters  became  stercoraceous  six  days  before  death. 

It  will  be  seen  that  in  both  cases  there  are 
evidences  of  incomplete  obstruction.  The  constipation 
alternates  with  an  occasional  motion.  In  some  of  the 
other  less  acute  cases  the  patient,  when  not  al>solutely 
constipated,  passed  many  scanty  and  very  liquid  stools. 
The  vomiting  is  not  severe  at  first,  and  occurs  at  long 
intervals.  The  abdominal  pain  is  paroxysmal.  There 
is  a  dragging  pain  about  the  part  to  w^iicli  the  gut 
is  adherent.  There  is  not  much  distension  of  the 
abdomen.  In  the  chronic  cases  the  movements  of 
the  intestinal  coils  are  visible. 

In  one  instance,  where  the  ileum  was  adherent  to 
the  ovary  and  formed  many  angular  bends,  an 
irritable  diarrhoea  took  the  place  of  the  more  usual 
constipation,    and   the    patient   only    vomited    twice 


fciiap. vi.i       Compression  by  Adhesions.  tii 

during  the  month  that  immediately  preceded  her 
death.  Such  a  case  hardly  comes  clinically  under  the 
category  of  intestinal  obstruction. 

4.  Obstructions  t>y  means  of  adhesions  tliat 
compress  the  g^ut.— Peritoneal  adhesions,  when 
favourably  placed,  may  undergo  considerable  contrac- 
tion. When  placed  upon  the  bowel  these  false 
membranes  may,  by  their  shrinking,  so  compress  the 
intestine  as  to  seriously  narrow  its  lumen.  Exjoeri- 
ence  demonstrates  a  fact  that  might  have  been  anti- 
cipated, viz.  that  this  form  of  constriction  is  most 
usually  met  with  about  the  most  fixed  segments  of 
the  intestine,  that  is  to  say,  about  the  ascending  and 
descending  colon,  and  the  hepatic  and  splenic  flexures. 
The  process  involved  in  certain  of  these  cases  where 
the  colon  is  concerned  is  intelligible  enough.  Thus, 
says  Leichtenstern,  "  A  circumscribed,  chronic,  con- 
stricting peritonitis  is  sometimes  found  at  the  flexures 
of  the  colon.  As  the  results  of  atony  of  the  muscu- 
lar coat  repeated  fsecal  accumulations  are  found  espe- 
cially at  the  flexures,  the  points  where  the  obstacles 
to  the  advance  of  the  fseces  are  greater.  TJie 
frequently  repeated  irritation  of  the  peritoneum  pro- 
duced thereby  excites  chronic  peritonitis,  which  may 
result  in  constriction.  In  other  cases  the  chronic 
peritonitis  starts  from  the  concavity  of  the  liver  and 
extends  to  the  flexura  hepatica ;  it  is  set  up  at  the 
former  point  by  gall  stones,  neoplasms,  etc.,  or  is  the 
continuation  of  a  cirrhotic  process  in  the  liver,  or  of 
a  portal  periphlebitis.  In  the  left  hypochondrium 
we  sometimes  find,  together  with  numerous  splenic 
adhesions  and  fibrous  perisplenitis,  the  splenic  flexure 
adherent  and  constricted  by  chronic  fibrous  perito- 
nitis."* In  other  instances  the  cause  of  the  con- 
stricting peritonitis  is  not  so  evident.  An  example  of 
such  cases  is  afforded  by  a  specimen  in  the  London 
*  Loc.  cit. ,  page  632. 


1 12  IntestiN'al  Obstruction.        [Chap.  vi. 

Hospital  *  (Fig.  22).  Here  the  ascending  colon  just 
above  the  csecum  is  narrowed  by  an  isolated  patch  of 
contracting  adhesions  so  as  to  produce  considerable 
stenosis.  It  is  probable  that  in  this  case,  and  in 
others  like  it,  the  limited  peritoneal  inflammation  has 
been  induced  by  an  ulcer  of  the  mucous  membrane, 
although  the  evidence  of  this  in  the  present  specimen 
is  not  clear.  The  association  of  cicatricial  strictures 
of  the  bowel  with  a  constricting  peritonitis  is  well 
known,  and  is  illustrated  by  a  vast  number  of  recorded 
cases  and  museum  specimens.  A  specimen  in  Guy's 
Hospital  affords  a  good  example  of  a  constriction  at 
the  splenic  flexure  due  to  adhesions,  f  In  some  of 
these  instances  the  patient  has  given  a  history  of  a 
previous  attack  of  enteritis. 

The  extent  to  which  the  bowel  is  naiTow^ed  in 
these  cases  is  often  considerable.  In  some  the  aftected 
colon  would  barely  admit  the  tip  of  the  little  finger. 
In  others  it  would  only  admit  a  crow-quill. 

In  a  singular  specimen  from  the  College  of 
Surgeons  Museum,  one  of  the  appendices  epiploicae 
has  contracted  such  an  adhesion  to  the  attached 
omentum  as  to  cause  constriction  of  the  bowel.  | 

I  have  found  but  few  examples  of  this  form  of 
obstruction  in  the  small  intestine.  In  every  instance 
there  has  been  some  complication  in  the  case.  The 
affected  bowel  is  always  adherent  to  the  parietes  or 
to  the  pelvic  viscera.  In  two  cases  reported  by  Dr. 
Fagge  (in  one  of  which  the  ileum  was  involved  and 
in  the  other  the  jejunum)  adhesions  existed  elsewhere, 
and  the  final  obstruction  was  complicated  by  angular 
bending  of  the  intestine  about  the  point  of  its  at- 
tachment.§     Mr.  Gay  has  reported  a  case  where  eight 

*  London  Hospital  Museum,  No.  Ae.  84. 
t  Guy's  Hosp.  Museum,  No.  1,852. 
t  Coll.  of  Surgeons  Museum,  No.  1,302. 
f  Loc.  cit. 


Chap,  vf.]        Matting  of  the  Bowels. 


^^3 


inches  of  tlie  ileum  were  adherent  to  the  fundus  of  a 
uterus  ''  in  a  state  of  scirrhous  degeneration."  The 
intestine  so  involved  was  so  narrowed  as  to  barely 
admit  a  goose-quill.*  It  is  doubtful  if  this  case  would 
fall  under  the  present  category. 

As  regards  the  symptoms  incident  to  this  vaiiety 
of  obstruction,  it  can  only  be  said  that  they  more  or 
less  completely  resemble  those  due  to  stricture  of  the 
bowel.  In  the  case  of  the  colon  this  assertion  may  be 
made  without  reservation.  In  the  case  of  the  small 
intestine  the  manifestations  of  the  disease  appear  to 
exhibit  a  more  rapid  development  than  is  usual  in 
stricture,  the  permanent  stenosis  being  complicated  by 
the  effects  of  angular  bending. 

5.  Obstriictioii  hy  tlie  iiiattiiBs;  to^ethor  of 
intestinal  eoils.— The  many  cases  that  can  be 
classed  under  this  category  present  a  protean  aspc-ct. 

1.  The  small  intestine.  —  The  coils 
of  the  lesser  bowel  may  be  matted  together 
in  many  different  ways.  In  one  set  of 
cases  a  small  segment  of  the  gut  is  so 
adherent  as  to  form  a  permanent  and  un- 
changing loop.  In  another  set  of  cases, 
many  coils,  involving  often  a  considerable 
tract  of  the  intestine,  are  matted  together 
so  as  to  form  more  or  less  complicated 
masses.  In  both  instances  the  involved 
coils  are  usually  quite  free  from  adhesions 
to  the  parietes  or  to  other  viscera. 

In  the  Ji7'st  set  of  cases  a  simple  per- 
manent loop  is  formed  in  the  bowel.  This 
loop  may  be  open,  the  walls  of  tlie  gut 
being  adherent  only  at  the  extremities  of 
the  loop  (Fig.  19a  and  Fig.  20),  f  or  it 
may  be  closed,  the  walls  of  the  involved  bowel  being 

*Path.  Soc.  Trans.,  vol.  iii.,  page  108. 

t  Guy's  HosiJ.  Museum  Eeports,  183G,  page  21. 

1—12 


114  Intestinal  Obstruction.        [Chap.  vi. 

adherent  in  their  entire  extent  (Fig.  19  b).     The  latter 
variety  involves  a  much  smaller  amount  of  intestine 


Fig.  20. — Adhesions  forming  the  Bowel  into  a  Loop. 
A  probe  Is  introduced  into  a  perforation  in  tbc  intestine. 

i-han  does  the  former.*  There  are  several  distinct  condi- 
tions under  which  these  distortions  of  the  bowel  may  be 
produced.  Many  are  the  results  of  hemise.  If  a  coil 
of   good   size   be    involved    in  a  rupture   and   much 

*For  specimens  of  these  loops  see  St.  Bart.'s  Hosp.  Miiseum, 
No.  2,100  ;  Path  Soc.  Trans,,  vol.  x.,  case  by  Mr.  Birkett ;  and 
St.  Thomas's  Hosp.  Museum,  Q  No.  128. 


Chap.  VI.] 


Intestinal  Loops. 


^'5 


compressed  by  the  hernial  orifice,  adhesions  may  form 
at  the  point  compressed,  and  a  permanent  open  loop  be 
formed  after  the  gut  has  been  reduced.  If  the  her- 
niated coil  be  small  (a  mere  knuckle)  a  closed  loop 
m^j  result  from  the  adhesions  produced  l^y  inflamma- 
tion of  the  serous  coat. 

Then  again  an  ulcer  of  the  mucons  membrane  may, 
by  inducing  a  limited  peritonitis,  lead  to  the  forma- 
tion of  a  loop.  If  the  adhesions  are  scanty  and  iso- 
lated, an  open  loop  is  produced  as  in  Fig.  20 ;  if 
extensive,  a  closed  loop  as  in  the  si^ecimen  (N^o.  Q 
1 28)  in  St.  Thomas's  Hospital  Museum. 

In  other  cases  the  loop-prodncing  adhesions  are 
the  result  of  mesenteric  gland  disease,  and  I  have  seen 
two  preparations  where  a  broken  down  or  caseous 
gland  has  occupied  the  angle  formed  by  the  two  limbs 
of  the  loop. 

Sometimes  a  fistulous  passage  connects  the  cavities 
of  the  two  portions  of  bowel 
at  the  root  or  narrow  part 
of  the  loop.  Such  a  passage 
is  known  as  a  fistula  biniu- 
cosa.  They  most  frequently 
result  from  idiopathic  ulcers 
of  the  intestine,  but  may 
follow  also  from  the  destructive 
processes  induced  by  compres- 
sion."^ 

One  of  the  most  remarkable 
cases  of  fistula  bimucosa  is 
aftbrded  by  a  report  of  Dr.  Bris- 
towe's  in  the  Pathological  So- 
ciety's Transactions  t  (Fig.  21). 
Here  the  transverse  colon  communicated  with  the  ileum 
at  two  points  through  a  cavity  whose  walls  were  formed 

*Path.  Soc.  Trans.,  vol.  x. ;  Mr.  Birkett's  case, 
t  Vol.  xiv.,  1863,  page  201. 


Fig.  21. — Fistula  Bimucosa, 
with  formation  of  a  Loop 
in  tlie  Ileum. 


ii6  Intestinal  Obstruction.         [Chap. vi. 


Fig.  22.— Stenosis  of  ascendingr  Colon  from  the  contraction  of  Peritoneal 

Adhesions. 


Chap.  VI.]  Intestinal  Loops.  ii7 

by  firm  adhesions.  The  patient  died  with  symptoms 
of  phthisis  and  dysenteric  diarrhoea,  and  there  is 
little  doubt  but  that  the  primary  mischief  was  caused 
by  a  perforating  ulcer  of  the  transverse  colon. 

It  does  not  appear  that  the  open  loop  ever  of  itself 
leads  to  definite  obstruction.  In  cases  where  a  fistula 
bimucosa  exists  a  fatal  perforatioi).  may  form  in  the 
gut  above  the  seat  of  the  sinus.  This  may  be  due  to 
fresh  ulceration  of  the  bowel  formed  independently  of 
any  obstruction  effects.  In  Mr.  Birkett's  example  of 
a  fistula  bimucosa  following  a  strangulated  rupture,  a 
like  termination  to  the  case  ensued,  although  the 
cause  of  the  perforation  in  this  instance  was  not  evi- 
dent. The  open  loop  may  become  twisted,  and  so 
cause  obstruction,  while  it  forms  an  excellent  point 
d'appui  around  which  a  normal  coil  may  become  in- 
volved in  a  volvulus.  Sir  Astley  Cooper,  in  his 
treatise  on  hernia,  mentions  a  case  where  "  two  folds 
of  intestine  had  adhered  at  one  point  only  (as  may  be 
represented  by  bringing  the  points  of  the  thumb  and 
finger  in  contact).  Through  the  noose  thus  formed 
another  fold  of  intestine  had  passed,  and  had  become 
strangulated." 

The  closed  loop  very  usually  leads  to  obstruction 
of  the  intestine.  Here  the  adherent  bowel  is  so 
acutely  bent  that  a  fold  of  mucous  membrane  projects 
into  the  lumen  of  the  intestine,  and  offers  a  valve-like 
impediment  to  the  passage  of  matters  (Fig.  23  a). 
The  gut  above  the  bend  in  time  enlarges  from  disten- 
sion until  it  forms  an  actual  ampulla  (Fig.  23  b)  and 
so  renders  the  passage  of  the  contents  of  the  bowel 
still  more  difficult.  A  remarkable  case  fully  reported 
by  M.  Nicaise  "^  affords  an  example  of  this,  and  from 
his  case  Fio^.  23  b  is  taken.  In  this  case  the 
ampulla  was  so  large  that  the  lower  segment  of  the 

*Bull.  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  tome  vi.,  1880, 
page  582. 


ii8 


Intestinal  Obstruction. 


[Chap.  VI. 


these 
with 
upon 


bowel  appeared  to  issue  fiom  the  side  of  it  rather  than 
from  the  end.  The  parts  are  compared  by  M.  Nicaise 
to  the  c?ecum  and  the  entering  ileum.  The  aperture 
was  valve-like,  and  just  admitted  the  tip  of  the  index 
finger.      The  patient,    a  man  aged   twenty -five,  had 

been  operated  upon  for  a 
strangulated  inguinal  hernia 
five  years  before  the  fatal 
obstruction  came  on. 
The  symptoms  in 
cases  may  be  classed 
those  that  depend 
stricture  of  the  lesser  bowel^ 
although  they  are  perhaps 
liable  to  more  acute  modes 
of  termination."^  In  M. 
Nicaise's  case  the  patient 
had  been  troubled  during 
the  five  years  that  followed 
the  reduction  of  his  hernia  with  attacks  of  colic,  with 
occasional  vomiting  and  with  diarrhoea,  alternating 
with  constipation.  Eight  days  before  the  man's 
death,  which  occurred  shortly  after  an  enterotomy 
had  been  performed,  he  was  seized  with  somewhat 
acute  symptoms  associated  with  much  vomiting,  with 
occasional  action  of  the  bowels,  but  with  no  abdominal 
tenderness,  and  with  little  jDain.  The  movements  of 
the  intestinal  coils  were  visible  through  the  parietes. 
The  fatal  issue  had  probably  been  provoked  by  the 
administration  of  purgative  medicines  which  had 
hurried  much  intestinal  matter  into  the  amjjulla  and 
so  produced  the  obstruction. 

Apropos   of    these    cases,    one    might    notice    an 


B 


Fig.  23. 


*  M.  Bricheteau  (Bull,  de  la  Soc.  Anat.  Je  Paris,  1862,  page 
257)  rwjiorts  a  case  of  occlusion  by  a  closed  loop,  the  exact  cause  of 
■which  is  obsciH-e,  where  the  patient  died  with  acute  symptoms  in 
twelve  days. 


cW- VI.]       Matting  of  the  Bowels.  tip 

instance  of  obstruction  of  the  lesser  bowel  by  a  large 
gall-stone  where  the  gut  at  the  obstructed  point  was 
bent  upon  itself  and  the  bend  retained  in  a  fixed 
position  by  adhesions,  apparently  of  recent  formation.* 
In  the  second  set  of  cases,  alluded  to  at  the  com- 
mencement of  this  paragraph,  certain  coils  of  the 
intestine  are  found  matted  together  in  a  confused 
mass.  The  condition  is  similar  to  that  met  with  in 
chronic  tubercular  peritonitis,  from  which,  however, 
it  must  be  distinguished.  The  tubercular  affection 
involves  the  whole  mass  of  the  intestine  and  is  a 
diffused  process.  In  the  present  set  of  cases  the 
causative  peritonitis  is  quite  local  and  only  a  portion 
of  the  lesser  bowel  is  involved.  The  adherent  coils 
usually  form  a  roundish  mass,  which  may  be  almost 
as  distinct  as  a  tumour,  and  which  compares  con- 
spicuously w^ith  the  uninvolved  and  normal  bowel. 
The  matted  intestine  may  also  be  adherent  to  the 
parietes,  or  it  may  be  quite  free.  Sometimes  the 
matting  is  brought  about  by  a  multitude  of  isolated 
adhesions.  In  other  cases  the  coils  are  enveloped  in 
fine  membranous  adhesions  so  that  they  may  appear 
as  if  enclosed  in  a  bag  of  tough  tissue  paper.  An 
example  of  this  latter  condition  is  afforded  by  Fig.  24. 
Some  of  the  coils  in  the  mass  may  be  of  normal 
lumen,  others  may  be  dilated,  and  many  may  be 
compressed.  They  are  commonly  strangely  distorted. 
When  obstruction  has  been  caused,  the  bowel  entering 
the  mass  will  be  found  dilated,  w^hile  that  leaving  it 
will  be  more  or  less  shrunken.  The  amount  of  gut 
involved  varies.  It  may  be  but  a  few  inches,  as  in 
a  case  reported  by  M.  Julliard,  where  six  inches  only 
were  involved,!  or  it  may  be  several  feet  as  in  an 

*Dr.  Van  der  Byl;  Path.  Soc.  Trans.,  vol.  viii.,  page  231. 
An  almost  precisely  similar  case,  minus  the  adhesions,  is  reported 
by  Dr.  Draper,  Neio  York  Medical  Journal,  1882,  j)agel7. 

+  Bull.  et  Mem,  de  la  Soc.  de  Chir.,  Paris,  tome  v.,  1872,  page 
627. 


120 


Intestinal  Obstruction.        [chap.  vi. 


instance  recorded  by  Dr.  Bristowe,  where  nearly  one 
half  of  the  ileum  was  found  matted  into  a  confused 
mass.^  In  several  instances  a  part  of  the  colon  has 
been  involved  in  the  adhesions,  as  was  the  case  in  a 
specimen  described  by  Mr.  Sydney  Jones,  where  the 
coils  of  the  lower  ileum  were  not  only  matted  together 
but  were  adherent  also  to  the  ceecum.f 


Fig,  24.— Diffused  Peritoneal  Adhesions. 

Various  forms  of  local  peritonitis  have  led  to  this 
condition  of  the  bowels.  It  has  followed  after  opera- 
tions upon  strangulated  hernia,  aftei*  ovariotomy, 
after  pelvic  peritonitis,  and  peritonitis  due  to  other 
lesions  than  operation  wounds.  In  one  case  at  least 
the  intestines  were  found  matted  together  by  a  peri- 
toneal inflammation  induced  by  cancer  of  the  bowel 
itself.  I 

*Path.  Soc.  Trans.,  vol.  viii.,  page  200. 

•\L<n\cd,  vol.  i.,  1883,  page  818. 

X  Bull,  de  la  Soc.  Auat.,  1877,  page  473 ;  M.  Regeard. 


Chap. VI.]         Matting  of  the  Bowels.  12 1 

The  symptoms  that  arise  are  in  tlie  main  identical 
with  those  associated  with  stricture  of  the  small  in- 
testine. The  onset  is  gradual,  the  progress  of  the 
malady  is  irregular,  severe  periodic  attacks  are  com- 
mon, and  an  acute  termination  to  the  case  is  not 
unusual.  Constijmtion  is  partial,  and  often  alter- 
nates with  a  copious  diarrhoea.  The  vomiting  is 
usually  slight,  irregular  in  occurrence,  and  uncertain 
in  duration.  During  an  exacerbation  of  the  symp- 
toms, and  especially  during  a  final  acute  attack,  it 
may  become  stercoraceous.  In  one  case  there  was 
constant  feculent  vomiting  for  fourteen  days  before 
death.  The  pain,  such  as  it  is,  is  paroxysmal,  the 
intervals  between  the  paroxysms  decreasing  as  the 
case  advances.  Early  in  the  case  there  may  be  an 
attack  of  colicky  j^ain  not  more  frequently  than  once 
or  twice  a  week.  Towards  its  termination  the 
paroxysms  may  come  on  at  intervals  of  a  few  minutes. 
The  patient  usually  emaciates,  and  the  movements  of 
the  distended  and  hypertrophied  coils  of  intestine 
above  the  obstruction  are,  as  a  rule,  evident  through 
the  parietes.  There  is  little  or  no  distension  of  the 
abdomen  unless  an  acute  form  of  obstruction  super- 
vene, and  even  in  such  a  case  the  meteorism  is 
usually  by  no  means  excessive.  In  two  or  three  in- 
stances the  mass  of  adherent  bowel  has  been  detected 
through  the  abdominal  parietes  as  an  ill-defined 
tumour.  That  the  tumour,  however,  may  be  some- 
times very  distinct  is  shown  by  a  remarkable  case 
reported  by  Dr.  Fleetwood  Churchi]!  in  his  work  on 
the  "  Diseases  of  Women."  The  patient  in  this  in- 
stance was  a  woman,  aged  twenty -three,  who  had  a 
tumour  in  the  lower  part  of  the  abdomen  on  the  left 
side,  that  was  dull  on  percussion.  It  was  diagnosed 
to  be  an  ovarian  growth.  She  had  never  had  any 
intestinal  symptoms.  The  abdomen  was  opened  by 
an  operation  intended  to  be  an  ovariotomy,  but  the 


t22  Intestinal  Obstruction.        [ciiap.  vi. 

tumour  was  found  to  be  composed  of  many  coils  of 
intestine  matted  together  by  old  adhesions.  Tlie 
wound  was  closed  and  the  patient  recovered. 

This  form  of  obstruction  seems  to  be  as  common 
in  men  as  in  women. 

The  duration  of  the  cases  when  once  symptoms 
have  appeared  varies,  and  may  be  reckoned  in  months 
rather  than  in  weeks.  In  one  case  due  to  peritonitis 
intestinal  symptoms  were  present  for  four  years 
before  a  final  and  acute  attack  came  on  which  ended 
in  death.  During  the  four  years  the  patient  had 
been  liable  to  colicky  pains,  and  to  an  obstinate  constipa- 
tion, which  at  the  end  of  two  years  changed  to  an 
equally  obstinate  diarrhoea.  In  other  instances  symp- 
toms resembling  those  due  to  stricture  of  the  lesser 
bowel  had  existed  for  two,  three,  four,  and  six  months 
respectively.  As  a  rule  they  made  their  appearance 
very  soon  after  the  causative  peritonitis.  In  one 
case,  reported  by  Dr.  Fagge,  the  patient  died  with 
symptoms  of  obstruction  that  had  continued  for 
twelve  days  after  the  relief  of  a  strangulated  hernia 
by  operation.  Here  coils  of  gut  were  found  matted 
together,  but  the  cause  of  death  was  due  most  pro- 
bably rather  to  the  direct  damage  to  the  bowel  in- 
flicted by  the  strangulation,  and  to  the  peritonitis, 
than  to  the  adhesions.  These  latter  had  formed  since 
the  operation. 

As  Dr.  Churchill's  case  shows,  even  an  extensive 
matting  together  of  intestinal  coils  need  not  be 
attended  by  any  evidences  of  intestinal  disturbance. 

2.  Tlie  larg^e  iiitestiue.— The  colon  being  a 
more  or  less  fixed  part  of  the  bowel,  it  follows  that  it 
is  not  susceptible  to  quite  the  same  morbid  conditions 
as  have  just  been  described  as  frequent  in  the  lesser 
bowel.  As  a  result,  however,  of  distension,  parts  of 
the  colon  may  become  greatly  elongated,  and  the 
abdominal   coils   thus    formed    may   become    matted 


Chap.  VI.]        Matting  of  the  Bowels.  123 

together  by  adliesions.  The  eftects  of  colic  distension 
are  often  well  seen  in  the  bowel  above  the  seat  of 
a  chronic  obstruction. 

I  can  find  no  case  where  the  descending  colon, 
the  most  fixed  part  of  this  bowel,  is  stated  to  have 
altered  its  position  to  any  conspicuous  extent  as  a 
result  of  distension."^  In  one  instance  a  dilated 
ascending  colon  appears  to  have  become  so  curved  that 
its  convexity  was  found  to  be  adherent  to  the  ovary,  f 
The  sigmoid  flexure  when  distended  is  apt  to  stretch 
towards  the  right  iliac  region,  and  then  to  mount 
up  into  the  right  hypochondriac  region.  The  two 
limbs  of  the  dilated  loop  may  be  found  matted  to- 
gether, or  the  summit  of  the  loop  may  be  found 
adherent  to  the  csecura,  to  the  peritoneum  in  the 
right  iliac  or  hypochondriac  regions,  or  even  to  the 
under  surface  of  the  liver.  The  transverse  colon 
undergoes  a  peculiar  and  common  change  when  much 
distended.  Its  central  point  tends  to  pass  down- 
wards towards  the  pelvis,  so  as  to  produce  a  V  or'U- 
shaped  bend  (Fig  25,  b).  The  apex  of  the  V  or  the 
bend  of  the  U  may  become  adherent  to  the  mesentery, 
or  to  the  peritoneum  about  the  pelvis,  or  to  a  pelvic 
viscus,  such  as  the  fundus  of  the  uterus.  |  One  limb 
of  the  V  may  become  adherent  to  the  whole  length  of 
the  ascending  colon,  §  and  so  produce  a  ''  double- 
barrelled  ascending  colon,"  or  the  other  limb  may 
attach  itself  to  the  descending  colon  in  a  like  fashion, 
and  produce  a  similar  appearance  on  the  left  side.  || 

*  Mr.  Ctu'ling  reports  a  case  of  stricture  of  tlie  rectum  where 
the  "  descending  colon  "  is  said  to  have  been  coiled  upon  itself, 
and  to  have  reached  the  right  iliac  fossa  ;  but  the  gut  in  question 
appears  to  have  been  rather  an  immense  sigmoid  flexure  (Path. 
Soc.  Trans.,  vol.  x.,  page  157).  , 

t  Duchaussoy  ;  Mem.  sur  I'Anat,  path,  des  Etrang.  internes, 
1860. 

X  ]\Ir.  Shaw;  Path.  Soc.  Trans.,  vol.  iv.,  page  147. 

§  Dr.  Hilton  Fagge,  loc.  cit. 

II  Bte  case  of  George  Luff  (page  125). 


124 


InTES  TINA  L    ObS  TR  UC  TION. 


[Chap.  VI. 


(Fig.  25,  c  and  d).  In  most  cases  this  deformity 
of  the  colon  has  been  the  result  of  chronic  obstruction 
in  the  lower  part  of  the  bowel,  such  as  a  stricture 
of  the  sigmoid  flexure  or  rectum. 

In   a   few  instances  it  would  appear  that  the  V- 
shaped  bend  may  be  rapidly  produced.     Thus,  in  a 

case  of  volvulus  of  the  sig- 
moid flexure  in  a  woman, 
aged  twenty-seven,  that 
ended  fatally  in  four  days, 
the  transverse  colon  was 
found  to  have  descended 
in  an  angular  loop  as  far 
as  the  pubes."^  It  is  quite 
common  at  autopsies  to 
find  this  ansfular  bend  in 
the  arch  of  the  colon  with- 
out intestinal  obstruction 
p  Q  of  any  kind  or  at  any  part. 

Pig.  25.  Such  examples  may  be  the 

result  of  chronic  constipa- 
tion, and  so  far  as  my  experience  extends  are  mostly 
met  with  in  the  aged,  in  those  over  sixty  more  often 
than  in  those  whose  ages  fall  between  fifty  and  sixty,  f 
There  are  cases  where  one  limb  of  the  bent  colic 
arch  is  found  adherent  to  the  ascending  or  descending 
colon  for  its  entire  length,  but  where  no  obstruction 
of  any  kind  is  found  in  the  gut  below  the  distorted 
segment.  I  am  disposed  to  ])elieve  that  such  cases 
d(^pend  upon  ulceration  of  the  colon.  The  ulceration 
leads  to  peritonitis,  distension  and  distortion  of  the 
transvcr.sc  colon  may  follow,  and  then  a  part  of  the 
altered  arch  may  become  adherent  to  the  inflamed 


*  Dr.  Fagge,  loc.  cit.  Assuming  that  the  bend  was  not  con- 
genital. 

t  In  several  cases,  appearing  in  young  patients  especially,  there 
id  no  doubt  but  that  the  distortion  of  the  colon  is  congenital. 


Chap. VI.]        Matting  of  the  Dowels.  125 

serous  coat  of  the  ulcerated  bowel.  Thus,  in  the  case 
reported  by  Mr.  Shaw,  the  position  depicted  in  Fig. 
25  c  was  found,  and  along  the  whole  length  of  the 
colon  were  discovered  the  cicatrices  of  ulcers.  It 
is  a  conspicuous  fact  that  in  these  cases  no  adhesions 
ai'e  usually  found  except  between  the  two  united 
segments  of  the  colon.  The  deformity  of  the 
ascending  colon  and  of  the  sigmoid  flexure  above 
alluded  to  is  due  probably  in  all  cases  to  distension 
following  obstruction  lower  down  in  the  bowel. 

No  abdominal  symptoms  may  be  excited  by  these 
conditions  of  the  colon,  although  there  is  more  usually 
some  evidence  of  simple  chronic  constipation.  The 
matting  of  the  sigmoid  flex\u"e  in  the  way  described 
is  very  apt  to  lead  to  volvulus  of  that  part ;  and  in 
the  case  of  the  deformed  and  adherent  colic  arch  more 
or  less  acute  obstruction  may  supervene  from  occlusion 
by  kinking. 

In  Mr.  Shaw's  case  subacute  symptoms  set  in. 
The  patient,  a  man  aged  sixty-three,  had  had  severe 
constipation  for  some  three  weeks  before  his  death. 
He  obtained  some  relief  by  aperients,  but  for  the  last 
seven  or  eight  days  of  his  life  the  constipation  had 
been  absolute.  He  vomited ;  his  abdomen  was  dis- 
tended and  tender  and  the  seat  of  colicky  pain.  He 
died  the  day  after  a  right  lumbar  colotomy  had  been 
performed.  The  case  was  complicated  by  tlie  presence 
of  a  fistula  bimucosa  between  the  ascendintf  colon 
and  the  jejunum.  This  accounted  for  the  stercoraceous 
vomiting  that  set  in  some  three  or  four  days  before 
death. 

The  following  case  may  be  quoted  as  presenting 
several  points  of  interest : 

George  Luff,  aged  seventy-three,  was  admitted  into  the 
London  Hospital  on  September  11th,  1882,  with  a  fracture 
of  the  femur  and  a  contusion  over  the  region  of  the  liver,  the 
results  of  a  fall.     He  is  said  to  have  never  had  any  abdominal 


126  Intestinal  Obstruction.         [Chap.  vi. 

troubles  and  to  have  enjoyed  good  health.  His  bowels  were  regu- 
lar. On  the  14th  he  vomited  a  little.  On  the  19th  he  developed 
some  evidences  of  local  peritonitis  about  the  seat  of  the  blow. 
He  again  vomited :  his  bowels  became  absolutely  confined,  and 
his  belly  was  distended  and  tympanitic.  He  became  rapidly 
worse,  the  vomiting  became  incessant,  although  never  stercora- 
ceous,  the  abdominal  pain  increased,  and  the  patient  died  on  the 
following  day,  the  20th.  The  autopsy  revealed  an  enormous 
distension  of  the  large  intestine  with  a  condition  of  the  trans- 
verse colon  similar  to  that  shown  in  Fig.  25  d.  The  descending 
part  of  the  colon  and  one  limb  of  the  distorted  transverse  colon 
were  firmly  blended  by  old  adhesions.  The  hepatic  flexiu'e 
was  connected  by  dense  fibrous  bands  to  the  liver  and  gall 
bladder,  and  over  this  spot,  which  corresponded  to  the  seat 
of  the  injury,  was  a  trifling  amount  of  recent  peritonitis.  The 
rest  of  the  peritoneum  was  qi;ite  normal.  The  mucous  mem- 
brane of  the  colon  was  unfortunately  not  examined ;  nor  was 
the  cause  of  the  mischief  about  the  hepatic  flexure  explained. 
All  parts  of  the  large  intestine  were  eq\ially  distended,  and  the 
rectum  was  normal.  Here  it  would  appear  that  the  old  man 
Buffered  no  inconvenience  from  his  distorted  colon  while  his 
health  was  good ;  but  the  shock  of  the  accident,  his  advanced 
age,  and  the  peritoneal  mischief  seem  to  have  thrown  the  colon 
hors  de  combat,  to  have  induced  a  pai-alysis  of  its  walls,  and  a 
sudden  cessation  in  its  functions.  Had  such  a  man  organic 
disease  of  his  heart,  or  advanced  disease  of  his  kidneys,  a 
similar  combination  of  circumstances  may  have  produced  a 
like  disturbance  in  the  functions  of  those  organs,  and  have  led 
to  a  still  more  rapid  death. 

6.  Obstruction  <liie  to  changes  effected  in 
the  intestinal  walls  as  a  result  of  traction. — 

The  form  of  stenosis  of  the  bowel  to  which  I  would 
here  call  attention  has,  so  far  as  I  am  aware,  not 
attracted  the  notice  of  those  who  have  written  upon 
the  subject  of  intestinal  obstruction,  or  perhaps  it 
would  be  more  proper  to  say  that  for  a  certain  series 
of  cases  I  have  ventured  to  propound  a  new  theory 
of  causation. 

It  would  be  well  to  commence  the  consideration  of 
this  matter  by  an  illustrative  case  that  is  fairly  typical 
of  the  series. 


Chap  VI.)       The  Effects  of  Tract/on.  127 

Dr.  Southey*  reports  tlie  case  of  a  boy,  aged  six- 
teen, who  died  with  symptoms  of  intestinal  obstruction 
that  had  lasted  for  ten  days.  The  attack  came  on 
suddenly  (during  perfect  health)  with  colicky  pains, 
retching,  and  purging.  The  diarrhoea  was  soon  re- 
placed by  absolute  constipation  that  persisted  until 
death.  Vomiting  came  on,  and  on  the  sixth  day  was 
feculent.  It  was  always  copious,  and  occurred  at 
long  intervals.  The  pain  also  was  intermittent  in 
character.  The  autopsy  revealed  slight  general 
peritonitis.  A  diverticulum,  four  inches  long,  passed 
from  the  ileum  to  be  atta,ched  to  the  anterior  abdominal 
wall  just  below  the  umbilicus.  Immediately  above 
the  diverticle  the  gut  was  so  contracted  that  it  could 
only  admit  the  tip  of  the  little  finger.  It  was  also 
deeply  ulcerated  here.  The  two  feet  of  bowel  that 
extended  between  the  abnormal  process  and  the 
caecum  were  intensely  congested.  The  lumen  of  the 
diverticle  was  equivalent  to  that  of  a  goose-quill. 
{See  Fig.  26.)  f 

It  is  suggested  in  this  case  that  the  constriction 
in  the  gut  was  congenital,  and  that  the  ileum  below 
the  diverticle  had  been  strangulated  between  that 
process  and  the  abdominal  parietes.  With  regaixl 
to  the  first  suggestion,  it  must  be  allowed  that  con- 
genital strictures  of  the  small  intestine  are  very  rare, 
and  do  not  seem  to  have  been  noticed  in  connection 
with  the  diverticulum  upon  which  so  many  authors 
have  written.  If  congenital,  it  is  strange  that  it 
never  produced  any  inconvenience  until  sixteen  years 
had  elapsed.  With  regard  to  the  second  suggestion, 
it  can  only  be  said  that  evidence  is  lacking  that  can 
demonstrate  the  spontaneous  reduction  of  an  acutely 
strangulated  loop,  except  under  the  circumstances 
detailed  in  a  previous  paragraph  (page  93).     If  the 

*  Clinical  Soc.  Trans.,  vol.  xv.,  1882,  page  159. 
t  St.  Bart.'s  Hosp.  Musevjn,  No.  2,175. 


128 


Intestinal  Obstruction. 


[Chap.  VI. 


gut  had  reduced  itself  in  the  present  instance,  it  must 
have  done  so  early  in  the  case,  and  yet  the  symptoms 


Fig,  26. — Stenosis  of  the  Ileum  above  the  origin  of  a  ti-iie  Diverticulum. 


deliberately  increased  in  severity  until  death  appeared. 
It    is,    moreovei-,    difficult    to    understand    how    the 


Chap.  VI.]        The  Effects  of  Traction.  129 

strangulation  could  have  been  effected  between  the  di- 
verticle  and  the  somewhat  distant  abdominal  parietes. 

I  would  rather  venture  to  suggest  that  the  case 
was  one  of  sudden  closure  of  the  gut  by  kinking, 
brought  about  by  traction  on  the  diverticle  and 
rendered  possible,  or  more  easy,  by  the  stenosis  of  the 
bowel  above  that  process.  The  more  important 
inquiry  relates,  however,  to  the  nature  of  this 
stricture  in  the  intestine. 

When  a  band  or  cord  is  adherent  to  some  point  on 
the  bowel,  that  band,  whether  short  or  long,  will  tend 
to  interfere  with  the  action  of  the  intestine  if  the 
least  traction  be  brought  to  bear  upon  the  band.  It 
will  tend  to  fix  it  more  or  less ;  it  Avill  interfere  with 
the  normal  passage  of  a  peristaltic  wave  through  it, 
and  it  will  prevent  the  bowel  from  straightening  itself 
out  as  that  wave  goes  by.  Moreover,  the  traction 
must  bend  the  gut  a  little,  and  so  afford  some  obstruc- 
tion to  the  passage  of  its  contents,  slight  though  that 
impediment  might  be  in  many  cases.  Intestinal 
matters  will  tend  to  linger  about  the  adherent  part, 
or  even  to  accumulate  there  ;  increased  action  will  be 
required  in  the  gut  above  to  prevent  stagnation ;  more 
blood  will  be  brought  to  the  part,  and  it  is  con- 
ceivable that  under  these  various  influences  the 
mucous  membrane  immediately  aboTe  the  point  of 
attachment  of  the  band  may  in  time  become  ulcerated, 
and  that  following  upon  that  ulceration,  cicatrisation 
and  stenosis  may  ensue.  It  is  significant  that  in  the 
present  case  the  gut  was  ulcerated,  and  that  the 
stenosis  xi^as  immediately  above  the  point  of  attach- 
ment of  the  diverticle. 

Like  cases  belongmg  to  this  class  show  similar 
changes. 

This  theory  as  to  the  causation  of  these  stenoses 
is  illustrated  and  supported  by  the  condition  found  in 
other  forms  of  adherent  bowel.  It  is  extremely 
J— 12 


130  Intestinal  Obstruction.         [Chap.  vi. 

common  to  find  that  an  adherent  loop  is  actually 
strictured  at  the  point  of  its  attachment,  and  equally 
common  to  discover  that  that  stricture  was  the  result 
of  ulceration.  Stenosis  of  adherent  bowel  may  be 
due  to  three  causes :  1.  The  gut  may  be  occluded  by 
actual  bending,  by  the  condition  I  have  to  ventured 
to  describe  as  the  "  closed  loop."  2.  A  primary  ulcer 
may  have  formed  in  the  bowel,  which  may  have  led  to 
peritonitis  of  a  limited  character,  and  from  that 
peritonitis  the  adhesion  may  have  followed.  3.  The 
ulceration  may  be  secondary,  as  above  described, 
and  subsequent  to  the  adhesion.  In  considering  this 
matter  I  have  carefully  excluded  the  first  two 
varieties ;  and  have  found  many  cases  where  a  coil  of 
normal  bowel  has  become  attached  to  some  point 
within  the  area  of  a  definite  peritonitis,  and  has  then 
become  more  or  less  extensively  stenosed. 

One  singular  case  may  be  mentioned  here  that 
may  throw,  even  if  a  little  obliquely,  some  light 
upon  this  matter.  A  patient  died  after  laparotomy 
performed  on  the  thirteenth  day  for  acute  obstruction 
depending  upon  strangulation  of  the  small  intestine 
by  an  omental  band.  The  band  was  composed  of  the 
free  end  of  the  great  epiploon,  and  by  the  traction  to 
which  it  had  been  subjected  it  is  evident  that  the 
transverse  colon  must  have  been  dragged  upon. 
During  the  progress  of  the  case  a  remarkable 
symptom  apj)eared ;  a  distended  transverse  colon 
became  prominent  and  distinctly  visible  as  to  its 
outhnes  through  the  abdominal  parietes.  The  autopsy 
showed  that  the  only  obstruction  present  was  situated 
in  the  ileum.*  Why,  then,  was  the  colon  not  in  the 
usual  state  of  partial  collapse  1  Is  it  not  possible 
that  the  sudden  and  severe  traction  upon  the  gut 
might  have  led  to  disturbance  of  its  function,   to  a 

*  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  tome  vi.,  1880, 
page  601. 


Chap.  VI.]        The  Effects  of  Traction.  131 

species  of  paralysis  of  its  walls,  and  so  permitted  the 
strange  condition  of  distension  that  it  exhibited  % 

To  return  to  the  original  subject,  some  examples 
may  now  be  given  of  this  variety  of  obstruction. 
Dr.  Southey  reports  another  case  (in  the  same  paper) 
of  a  girl,  aged  13  J  years,  who  died  with  general 
peritonitis  depending  upon  an  acute  obstruction  of 
six  days'  duration,  Four  years  previously  she  had 
been  under  treatment  for  severe  constipation.  At  the 
autopsy  a  diverticulum  extended  between  the  lower 
ileum  and  the  umbilicus.  The  gut  immediately  above 
it  was  so  constricted  as  to  have  a  diameter  of  only 
half  an  inch.  No  other  cause  of  obstruction  was 
found.  Here  also  there  is  little  doubt  but  that  the 
final  acute  attack  was  due  to  kinking,  rendered  more 
possible  by  the  stenosis,  which  had  been  in  existence 
probably  for  some  time.  The  symptoms,  especially  the 
intermittent  pain  experienced,  and  the  fact  that  the  con- 
stipation was  not  absolute  from  the  first,  well  accord  with 
the  ordinary  manifestations  of  occlusion  by  kinking. 

In  a  case  by  Dr.  Hare  a  diverticulum  one  and 
three  quarter  inches  in  length  was  adherent  to  the 
inguinal  canal  into  which  it  had  been  herniated.  The 
ileum  immediately  above  the  diverticle  was  so  nar- 
rowed as  to  be  only  two-eighths  of  an  inch  in  diameter. 
The  mucous  membrane  was  here  ulcerated,  and  a  fatal 
perforation  had  occurred."^  The  patient  had  had 
symptoms  of  some  chronic  obstruction  in  the  small 
intestine.  In  a  case  placed  on  record  by  M.  Carriere, 
a  maUj  aged  twenty- eight,  had  peritonitis  eighteen 
months  before  his  death.  Since  this  attack  he  had 
had  intermittent  griping  pains  with  constipation.  He 
ultimately  succumbed  to  an  acute  attack  of  obstruc- 
tion lasting  about  ten  days.  A  true  diverticulum 
arose  from  the  ileum   and  was  attached  to  the  gut 

*Path.  Soc.  Trans.,  vol.  viii.,  page  181. 


132  Intestinal  Obstruction.        [Chap.vi. 

lower  down.  Through  the  loop  thus  formed  a  coil  of 
small  intestine  had  been  strangulated  (the  cause  of 
the  final  acute  attack).  The  ileum  was  so  narrowed 
at  the  point  of  origin  of  the  diverticle  that  it  would 
barely  admit  the  little  finger.* 

In  the  Museum  of  the  Koyal  College  of  Surgeons 
is  an  interesting  specimen  (No.  1,361)  which  may,  I 
think,  be  regarded  as  an  example  of  the  present  con- 
dition. It  shows  a  diverticulum,  two  inches  in  length 
and  one  inch  in  width  at  its  base,  that  ends  in  a  cord 
two  and  a  half  inches  long  attached  to  the  mesentery 
one  and  a  half  inches  from  the  margin  of  the  gut. 
One  inch  above  the  origin  of  the  diverticulum  the  gut 
suddenly  becomes  narrowed  to  a  diameter  of  about 
half  an  inch,  and  remains  this  size  down  to  the  point 
at  which  the  abnormal  process  comes  ofi".  Both  above 
and  below  the  narrowed  segment  the  bowel  is  normal. 
Beneath  the  arcade  formed  by  the  adherent  pi'ocess 
two  loops  of  intestine  were  strangulated. 

Several  cases  very  similar  to  these  may  be  cited 
where  the  small  intestine  was  gi'eatly  contracted 
about  the  point  of  attachment  of  an  isolated  adhesion. 
The  relation,  however,  of  the  adhesion  to  the  stenosis 
in  these  instances  is  open  to  doubt,  f 

The  symptoms  in  these  cases  pertain  to  those 
associated  with  stricture  of  the  lesser  bowel.  In 
some  there  is  a  continuous  chronic  course,  with  inter- 
mittent pain,  partial  constij)ation  associated  with 
occasional  diarrhoea,  slight  sickness,  some  emaciation, 
and  in  time  visible  peristalsis.  Other  cases  are  mostly 
characterised  by  a  final  and  acute  attack  due  to 
kinking  of  the  adherent  bowel  or  to  blocking  up  of 
the  stenosed  segment. 

*  Bull,  de  la  Soc.  Anat.  de  Paris,  1864,  page  496. 

t  Mr.  Gay  ;  Path.  Soc.  Trans.,  vol.  iii.,  inige  101.  Mr.  Avery; 
ibid.,  vol.  iv.,  page  156.  M.  Guiter ;  Le  Progres  Medical,  1882, 
page  112. 


Chap,  vi.i    Shrinking  of  the  Mesentery.  133 

7.  Narrowing:  of  tlie  bowel  from  shrinking 
of  tlie  mesentery  after  inflammation. — When 
the  mesentery  has  been  extensively  inflamed  it  may 
subsequently  undergo  such  marked  and  extreme  con- 
traction as  to  greatly  narrow  the  bowel  to  which  it  is 
attached.  In  such  cases  the  involved  coils  are  often 
found  bound  down  to  the  spine  by  the  shortened 
mesentery  and  much  shrunken  in  appearance.  This 
is  very  often  the  result  of  mesenteric  gland  disease. 
I  might  refer  to  four  well  marked  examples,  all  in 
young  patients,  of  this  form  of  contraction."^ 

"We  also  meet,"  says  Leichtenstern,  "with  an 
insidious  process  of  chronic  peritonitis  in  a  diffuse 
form  spread  over  the  greater  portion  of  the  peri- 
toneum, especially  of  that  covering  the  mesentery, 
and  then  it  often  presents  a  certain  independent 
character,  and  causes  thickening  and  shortening  of 
the  mesentery,  thus  binding  the  convolutions  of  the 
small  intestine  down  to  the  vertebral  column.  This 
cirrhosis  of  the  peritoneum  (peritonitis  deformans, 
Klebs)  results  from  chronic  venous  congestion  in 
diseases  of  the  heart,  and  sometimes  exquisite 
examples  are  found  with  cirrhosis  of  the  liver  and 
atrophied  nutmeg  liver,  and  also  occasionally  with 
granular  atrophy  of  the  kidneys."! 

The  symptoms  that  arise  in  these  cases  are  practi- 
cally identical  with  those  of  stricture  of  the  small 
intestine,  or  with  those  of  matting  together  of  many 
coils  of  the  bowel.  It  would  appear  from  Dr.  Fagge's 
cases  that  the  evidences  of  obstruction  may  extend 
over  years,  e.g.  for  four  years  in  one  case,  for  two  in 
another. 

*Dr.  Hilton  Fagge  (loc.  cit.)  three  cases  ;  and  a  fourth  case 
by  the  same  physician,  in  Path.  Soc.  Trans.,  vol.  xxvii.,  page  157. 
fLoc.  cit.,  page  632. 


134 


CHAPTER    yil. 

VOLVULUS. 

Under  the  general  term  "  volvulus "  may  be  in- 
cluded two  distinct  methods  of  producing  obstruction. 
In  one  the  bowel  is  so  twisted  about  its  mesenteric 
axis,  or  even  in  rare  cases  upon  its  own  axis,  that  it 
becomes  occluded.  In  the  other  form  two  suitable 
coils  of  intestine  are  so  intertwined  or  knotted 
together  as  to  cause  also  an  obstruction  in  their 
lumina. 

The  subject  may  be  most  conveniently  considered 
under  the  following  heads  : 

1.  Volvulus  of  the  sigmoid  flexure. 

2.  Volvulus  of  the  ascending  colon  and  caecum. 

3.  Volvxdus  of  the  small  intestine. 

1.  VoIviilHs  of  the  sigmoid   flexure.— This 

part  of  the  bowel  may  be  occluded  by  either  of  the 
two  methods  just  named. 

(1)  It  may  be  twisted  upon  its  mesenteric  axis. 
(2)  It  may  be  intertwined  with  a  suitable  coil  of 
small  intestine. 

(1)  The  bowel  is  twisted  about  its  mesen- 
teric axis:  Pathology.— This  is  the  most  usual 
form  of  volvulus,  and  may,  indeed,  be  said  to  be  the 
only  form  that  is  at  all  common.  If  all  the  cases  of 
volvulus  of  the  intestine  be  considered  collectively,  it 
will  be  found  that  about  two-thirds  of  the  number  are 
instances  of  twist  of  the  sigmoid  flexure  about  its 
mesenteric  axis. 

The  normal  flexure  forms  a  loop  that  is  more  like 
a  capital  C  than  a  Greek  2.     It  first  passes  obliquely 


Chap.  vii.  j  Vol  vul  us.  135 

upwards  and  inwards,  then  bends  almost  vertically 
do^\^.lwards,  and  finally  ascends  in  an  upward  and 
outward  direction,  to  tenninate  in  the  rectum.  Its 
curves  and  its  outline  vary  greatly.  Its  meso-colon 
may  be  very  long.  In  normal  instances  it  has  been 
Ions:  enouo-h  to  allow  the  bowel  to  reach  to  the  um- 
bilicus,  and  even  to  stretch  as  far  as  the  csecum.  This 
condition  is  not  infrequently  seen  in  newly-born  chil- 
di'en,  in  whom,  as  is  well  known,  the  sigmoid  flexure 
is  relatively  very  large.  In  the  sigmoid  flexure  that 
is  usually  met  A\dth,  a  flexure  of  moderate  size  with 
moderate  curves  and  with  a  short  but  wide  meso- 
colon, volvulus  cannot  occur. 

The  aiTangement  of  the  gut  that  is  necessary  for 
the  production  of  a  volvulus  is  the  following  :  The 
loop  must  be  of  considerable  length,  the  meso-colon 
must  be  long  and  very  narrow  at  its  parietal  attach- 
ment, so  that  the  two  ends  of  the  loop  may  be  brought 
as  close  together  as  possible.  This  condition  is  shown 
in  Fig.  27  A,  where  it  will  be  seen  that  the  loose  and 
free  coil  has  practically  a  fixed  pedicle  around  which 
it  could  with  great  ease  be  twisted. 

This  arrangement  of  the  parts  may  be  congenital, 
although  such  a  circumstance  must  be  uncommon 
since  volvulus  of  the  sigmoid  flexure  is  extremely 
rare  in  the  young.  It  may  be  brought  about  by  peri- 
toneal adhesions,  especially  by  such  as  have  been 
formed  after  great  distension  of  the  bowel.  It  may 
be  readily  produced  by  inflammatory  conditions  in  the 
meso-colon  leading  to  cicatricial  contraction. 

The  commonest  cause,  however,  is,  without  doubt, 
chronic  constipation.  In  this  condition  the  flexure  is 
more  or  less  constantly  distended,  its  walls  become 
partly  paralysed  by  that  distension,  and  becoming 
filled  with  fsecal  matters  and  flatus,  it  hangs  down 
into  the  pelvis  an  inert  heavy  mass.  So  placed  it 
must  drag  upon  its  meso-colon,  and  while  the  position, 


136 


Intestinal  Obstruction.        [Chap.  vii. 


on  the  one  hand,  tends  to  elongate  that  membrane, 
it  appears,  on  the  other,  to  approximate  the  two  ends 
of  tlie  loop.  Possibly  the  slight  chronic  obstruction 
always  present  in  the  part  may  lead  to  a  little  local 
peritonitis  which  may  tend  to  render  permanent  the 
deformity  produced. 

When  the  loop  is  in  this  condition  it  is   easy  to 
understand  that  a  twisting  of  it  upon  its  mesenteric 


Pig.  27.— Volvulus  of  the  Sigmoid  Flexure. 


axis  may  be  brought  about. 


Some  irregular  move- 


ment in  the  bowel  may  effect  this,  or  faeces  may  accu- 
mulate in  one  side  of  the  loop  only,  in  such  away  that 
the  weighted  end  could  fall  over  the  less  distended 
coil.  When  a  heavy  loop  blocked  with  faeces  is  con- 
cerned, the  position  of  the  body  may  become  a  factor 
in  the  causation  of  the  twist,  a  circumstance  that 
certain   cases   would    appear   to   illustrate.       Lastly, 


Chap.  VII.]  Volvulus.  137 

distension  of  the  bowel  alone  has  great  influence  in 
both  producing  and  maintaining  a  volvuluSj  a  fact  to 
which  further  allusion  will  be  made. 

According  to  Potain  there  are  two  kinds  of  twist. 
In  one  the  superior  part  of  the  loop  is  carried  from 
above  downwards,  and  from  behind  forwards,  in 
front  of  the  lower  half  of  the  loop,  so  that  the 
end  of  the  descending  colon  is  brought  into  contact 
with,  and  in  front  of,  the  commencement  of  the  rectum 
('^  type  rectum  en  arriere  "),  Fig.  27  b.  In  the  second 
form  the  superior  part  of  the  coil  is  carried  from 
above  downwards,  and  from  before  backwards,  be- 
hind the  lower  segment  of  the  loop,  so  that  the  end 
of  the  descending  colon  is  brought  into  contact  with, 
and  behind,  the  commencement  of  the  rectum  (''  type 
rectum  en  avant "),  Fig.  27  C. 

Of  these  two  A'arieties  the  former  is  by  far  the 
more  common.  The  twist  may  extend  through  an 
arc  of  180°  to  360°,  or  the  bowel  may  be  twisted 
twice  or  even  three  times  about  its  mesenteric  axis. 
Since  at  the  root  of  flexure  the  two  ends  of  the  loop 
are  nearly  parallel  to  the  mesenterial  axis,  it  follows 
that  when  the  latter  is  twisted  the  former  also  must 
be  twisted  upon  their  own  axes. 

When  the  volvulus  has  once  formed  it  is  soon 
made  permanent.  The  heavy  and  distended  coil  has 
no  power  of  straightening  itself.  Its  ends  being- 
closed  it  begins  to  increase  rapidly  in  size  from  dis- 
tension with  gas,  and  becomes  moreover  engorged  by 
blood  from  pressure  upon  the  vessels  that  enter  at  the 
pedicle  of  the  loop.  The  more  the  bowel  becomes 
distended  the  more  fixed  is  the  volvulus.  In  the 
autopsy  the  twist  may  be  almost  entirely  un- 
rolled by  main  force,  but  the  moment  the  hand  is 
removed  the  loop  springs  back  into  its  former  dis- 
torted position.  On  evacuating  the  gas,  however,  that 
distends  the  coil  the  volvulus  can  be  readily  reduced, 


138  Intestinal  Obstruction,       [Chap.vii. 

or  may  even  become  reduced  spontaneously.  In  other 
experiments  where  the  volvulus  has  been  reduced,  it 
has  been  made  to  immediately  reappear  upon  distend- 
ing the  bowel  from  above. 

The  unyielding  abdominal  parietes  (anterior)  take 
some  share  in  the  production  of  a  volvulus.  Melchiori 
has  demonstrated  this  by  experiments  made  upon  a 
body  that  presented  a  volvulus.  As  he  inflated  the 
now  untwisted  flexure  with  air  from  the  colon  it  be- 
gan to  form  a  volvulus,  but  as  the  coil  increased  in 
size  and  mounted  up  in  the  abdomen  it  gradually 
unwound  itself  again.  When,  however,  pressure  was 
applied  that  would  correspond  to  that  exercised  by 
the  anterior  abdominal  walls  the  volvulus  was  ren- 
dered permanent."^  In  some  cases  the  volvulus  may 
be  held  down  by  adhesions,  upon  the  division  of  which 
it  becomes  readily  reducible.!  In  other  instances  a 
coil  of  small  intestines  with  a  long  mesentery  may  be 
thrown  across  the  pedicle  of  the  volvulus  and  so  help 
to  maintain  its  permanency.! 

In  volvulus  the  occlusion  of  the  bowel  is  brought 
about  by  the  mutual  pressure  that  the  two  ends  of 
the  coil  exercise  upon  one  another.  The  loop  is 
therefore  closed  at  both  ends.  Cases  have  been  re- 
corded where  extensive  degrees  of  volvulus  have  been 
associated  with  a  narrowing  of  the  lumen  of  the  gut 
of  so  slight  a  character  as  to  cause  no  symptoms. 
Leichtenstern  reports  a  case  where  such  a  condition 
was  met  with  and  where  distension  actually  relieved 
the  volvulus.  The  specimen  was  from  the  body  of  a 
boy,  aged  eleven,  who  had  had  no  intestinal  troubles.  He 
presented  a  chronic  twisting  of  the  flexure,  with  close 
approximation  of  the  ends  of  the  loop.     "  If  air  is 

*  Quoted  by  M.  Liebaut,  Du  Volvulus  de  I'lliaque  du  Colon. 
TMse  de  Paris,  1882. 

t  Case  by  Dr.  Atherton ;  Boston  Med.  and  Surg.  Journ.^ 
1883,  page  531. 

X  Case  by  M.  Leger  ;  Bull,  de  la  Soc.  Anat.  de  Paris,  1875. 


Chap.  VII.]  Volvulus.  139 

forced  in  from  the  side  of  the  colon,  the  S  loop  un- 
twists, and  again  resumes  its  twisted  position  when 
the  air  is  allowed  to  escape,  a  proceeding  that  must 
have  been  repeated  during  life  with  every  passage  of 
fseces." 

At  the  autopsy  in  fatal  cases  the  sigmoid  flexure  is 
found  to  be  enormously  distended.  It  seems  to  occupy 
the  whole  abdominal  cavity.  The  rest  of  the  colon 
and  the  small  intestines  lie  behind  it  and  are  more  or 
less  hidden  by  it.  In  cases  of  slight  distension  the  loop 
about  reaches  to  the  umbilicus.  As  it  becomes  more 
distended  it  tends  to  move  towards  the  right  hypo- 
chondriac region.  It  then  lies  in  front  of  the  stomach 
and  ultimately  reaches  the  liver.  In  severe  cases  the 
diaphragm  is  much  pressed  upon  and  may  be  pushed 
up  to  within  16  cm.  (6|  inches)  of  the  clavicle,  or 
even  up  to  the  level  of  the  third  or  fourth  rib."^  In 
one  instance,  fatal  at  the  end  of  seven  days,  the 
diaphragm  had  been  raised  to  the  level  of  the  third 
rib,  the  lung  had  been  much  compressed,  while  its 
lower  parts  were  hepatised  and  empty  of  air.  f 

The  twisted  coil  is  more  or  less  intensely  con- 
gested. In  colour  it  may  present  any  depth  between 
a  dark  red  and  a  black.  Its  walls  are  often  much 
thickened  by  infiltration,  and  are  softened  and  friable. 
The  serous  coat  is  very  commonly  found  to  exhibit 
a  rent,  or  even  several  rents.  These  may  be  exten- 
sive and  often  involve  the  muscular  coat  also,  whilst 
the  mucous  membrane  escapes.  I  am  not  aware 
that  these  rents  have  ever  led  to  actual  rupture  of 
the  twisted  loop  during  life,  nor  can  I  find  any  case 
where  perforation  of  the  loop  has  occurred  from  ulce- 
ration of  its  mucous  lining.  If  the  patient  lives  long 
enough  and  the  case  is  severe,  the  walls  of  the  flexure 

*  Li^baut,  loc.  cit. 

fDr.  Esau  ;  Deutches  Archiv  fiir  clinischeMed.,  b.  xvi.,  1875, 
page  474. 


140  Intestinal  Obstruction.       [Chap.  vii. 

become  gangrenous.  This  gangrene  is  met  with  in 
the  form  of  one  or  more  patches  that  involve  all  the 
coats  of  the  bowel. 

The  twisted  loop  will  be  found  to  contain  much 
flatus,  and  to  be  otherwise  occupied  by  fluid  faecal 
matter  mixed  with  harder  masses.  Sometimes  the 
contents  are  entirely  solid,  and  in  other  instances  en- 
tirely liquid.  Blood,  often  in  considerable  quantity, 
may  be  found  mixed  with  these  contents.*  The 
twisted  meso-colon  will  be  of  a  violet  or  purple  colour 
and  engorged  with  blood. 

The  rest  of  the  intestines,  and  especially  the  colon, 
are  distended.  The  distension  seems  to  be  only 
limited  by  the  size  of  the  sigmoid  flexure.  In  cases 
where  the  involved  loop  is  of  enormous  size  the 
distension  of  the  rest  of  the  intestine  is  usually 
comparatively  slight,  the  gut  actually  lacking  room 
within  which  to  expand.  The  descending  colon  is 
often  much  enlarged  and  congested.  I  find  that  only 
twice,  in  twenty  recorded  cases  that  I  have  collected, 
has  perforation  occurred.  In  one  instance  the  per- 
foration was  in  the  caecum,  in  the  other  in  the  bowel 
just  above  the  volvulus.  In  one  or  two  instances 
the  mucous  membrane  in  the  lower  part  of  the 
descending  colon  is  described  as  being  rent. 

Peritonitis  is  singularly  constant  in  this  affection. 
It  develops  early,  commences  upon  the  involved 
bowel  and  then  spreads  over  the  rest  of  the  serous 
membrane.  In  seventeen  of  the  twenty  cases  just 
alluded  to  the  state  of  the  peritoneum  is  described. 
In  only  two  cases  out  of  this  number  was  there  no 
peritonitis.  In  one  of  these  examples  the  patient  had 
died  in  forty-eight  hours,  in  the  other  he  died  suddenly 
at  the  onset  of  the  attack.  In  the  remaining  fifteen 
cases  there  was  peritonitis.    In  one  of  these  instances 

*  In  a  case  by  Dr.  Crisp,  the  coil  contained  a  pint  of  thick 
blood;  Path.  Soc.  Trans.,  vol.  xxiii.,  page  112. 


Chap.  VII.]  Volvulus.  141 

it  was  still  limited  to  the  sigmoid  flexure  (the  patient 
had  died  on  the  fourth  day).  In  two  instances  there 
was  perforation.  The  remaining  cases  were  simple 
examples  of  acute  difi'used  peritonitis. 

In  many  instances  there  was  much  bloody  fluid 
in  the  peritoneum. 

Symptoms.  Frequency.  —  Volvulus  of  the 
sigmoid  flexure  forms  about  :^th  part  of  all  cases 
of  intestinal  obstruction."* 

Sex  and  age. — It  occurs  much  more  frequently 
in  men  than  in  women.  Of  my  twenty  cases,  sixteen 
were  males  and  four  females.  The  great  bulk  of  the 
cases  fall  between  the  ages  of  forty  and  sixty.  The 
average  age  in  the  twenty  cases  was  forty-nine,  the 
youngest  patient  being  twenty-seven,  the  oldest 
seventy-two.  It  is  rare  before  thirty,  and  extremely 
rare  before  twenty.  Leichtenstern  mentions  one  case 
in  a  child  aged  ten.  This  circumstance  of  age  has 
been  explained  by  the  greater  frequency  of  constipa- 
tion in  those  past  middle  life,  and  by  the  possibility 
that  the  condition  of  the  gut  that  favours  volvulus 
may  require  some  years  for  preparation. 

Previous  history  and  mode  of  onset.— In 
no  less  than  fourteen  out  of  the  twenty  cases  collected 
there  is  a  history  of  a  previous  chronic  constipation. 
Many  of  the  patients  had  suffered  from  obstinate 
constipation  for  years,  others  for  months  only.  In 
several  instances  there  had  been  attacks  of  colic, 
associated  mth  some  swelling  of  the  abdomen  and 
with  nausea,  if  not  with  actual  sickness.  In  a  few 
examples  diarrhoea  had  now  and  then  alternated 
with  constipation,  the  purging  being  probably  of 
a  spurious  character,  and  akin  to  that  associated  with 
the  constipation  in  stricture  of  the  rectum.  In  no 
instance  had  these  previous  symptoms  been  of  a  very 

*  Excluding  hernia,  diaphragmatic  hernia,  and  affections  of 
the  rectum. 


142  Intestinal  Obstruction.       [chap.vii. 

severe  character,  nor  reached  the  gravity  often 
observed  in  attacks  of  obstruction  that  have  preceded 
fatal  strangulation  by  bands  and  diverticula. 

The  mode  of  onset  is  usually  abrupt,  often  sudden. 
This  was  observed  in  twelve  out  of  eighteen  cases 
where  the  precise  manner  in  which  the  disease  com- 
menced was  noted. 

The  symptoms  begin  with  sudden  pain  in  the 
abdomen,  with  some  slight  degree  of  collapse  in  many 
instances,  and  are  soon  associated  with  swelling  of 
the  abdomen  and  nausea  or  even  vomiting.  In  some 
cases  the  attack  had  been  preceded  by  an  unusually 
long  period  of  constipation.  In  two  instances  out  of  the 
twenty  cases  it  had  followed  upon  an  attack  of  diar- 
rhoea. In  several  examples  it  came  on  after  a  meal, 
or  some  time  after  eating  indigestible  food.  Thus 
a  case  is  reported  of  fatal  volvulus  after  eating  many 
cherries  together  with  their  stones.  In  this  instance 
many  stones  were  removed  by  enema  and  ejected  by 
vomiting,  the  total  quantity  thus  evacuated  being 
"about  a  quart. ""^  In  several  of  the  cases  of  sudden 
onset  no  cause,  probable  or  improbable,  could  be 
assigned  for  the  attack.  In  one  case  the  patient  had 
had  many  previous  attacks  of  colic  with  distension, 
which  were  always  relieved  by  lying  in  a  particular 
position  upon  his  back  with  the  legs  bent.  In  the  last 
attack  the  position  failed  to  give  relief.  In  the  cases 
where  the  onset  is  not  sudden  there  is  usually  a 
history  of  obstinate  constipation  for  days,  associated 
with  distension  of  the  abdomen,  with  a  feeling  of 
malaise,  and  loss  of  appetite.  Then  nausea  appears, 
or  the  patient  is  troubled  with  eructations,  colicky 
pains  gradually  develop  and  the  symptoms  rapidly 
progress  as  in  the  more  acute  attacks. 

In   several   instances   an   acute   aspect  has  been 

given  to  the  case  by  the  administration  of  an  aperient. 

*  Dr.  Atherton ;  Boston  Med.  and  Surg.  Jowrn.y  1883,  jjage  531. 


Chap.  VII.]  Vol  vvl  us,  143 

Fain  is  usually  the  earliest  symptom,  and  is  a 
marked  feature  of  the  affection.  As  a  rule,  however, 
it  is  neither  so  conspicuous  nor  so  severe  as  it  is 
in  cases  of  strangulation  by  bands.  One  does  not 
read  of  the  patient  being  "bent  double"  by  it,  nor 
of  his  "rolling  on  the  floor"  in  pain,  nor  of  his 
"writhing  in  agony,"  expressions  that  are  not  un- 
commonly met  with  in  the  description  of  the  latter 
form  of  obstruction.  The  pain  is  often  paroxysmal 
at  first ;  a  feature  that  probably  indicates  that  the 
obstruction  is  not  at  the  onset  quite  complete.  In 
some  marked  cases  of  paroxysmal  pain  the  patient 
has  passed  a  motion  after  the  commencement  of  the 
attack.  The  pain  soon  becomes  constant  but  presents 
exacerbations.  The  constant  pain  may  be  due  to  the 
volvulus  itself,  the  exacerbations  to  an  increase  in 
the  twist  from  peristaltic  action.  The  more  acute  the 
case  the  more  severe  the  pain.  It  is  at  first  com- 
plained of  about  the  umbilicus,  or,  less  frequently, 
I  think,  about  the  seat  of  the  sigmoid  flexure  itself. 
As  the  case  advances,  and  as  peritonitis  sets  in,  the 
pain  becomes  more  diffused,  being  often,  however,  most 
felt  about  the  region  of  the  distended  coil.  It 
appears  to  diminish  rather  than  to  increase  as  the 
malady  advances.  There  are  cases  where  most  pain 
has  been  experienced  about  strange  parts,  such  as 
the  pubes  and  the  upper  and  left-hand  side  of  the 
abdomen. 

Tenderness  on  pressure  is  absent  at  first, 
although  when  the  early  pain  is  felt  about  the  region 
of  the  volvulus,  pressure  there  may  add  to  its  in- 
tensity. As  peritonitis  commencing  in  the  distorted 
loop  is  very  constant,  it  happens  that  tenderness  soon 
develops  over  the  region  the  gut  occupies^  and  as  the 
peritonitis  becomes  general  so  also  does  the  tenderness 
become  diffused.  There  is  no  form  of  intestinal 
obstruction  where  marked  pain  on  pressure  is  eKcited 


144  Intestinal  Obstruction.       [Chap.vii. 

earlier  than  in  the  present  cases,  if  exception  be  made 
of  certain  examples  of  acute  intussusception. 

Vomiting:  is  by  no  means  so  conspicuous  a  symp- 
tom as  it  is  in  strangulation  by  bands.  It  appears 
less  early  and  may  on  the  whole  be  spoken  of  as 
not  being  very  severe.  In  six  cases  out  of  twenty 
vomiting  may  almost  be  said  to  have  been  absent. 
Three  of  the  patients  did  not  vomit  at  all ;  of  the 
others,  two  only  vomited  after  food,  and  one  patient 
was  sick  but  once,  and  that  was  after  a  dose  of  castor 
oil.  These  patients  lived  respectively  forty-eight  hours, 
sixty-four  hours,  four  daysj(two),  seven  days,  and  eleven 
days  after  the  commencement  of  the  attack.  In  the 
first  of  these  cases  there  was  no  peritonitis,  in  the 
rest  it  had  not  reached  a  severe  grade,  while  the  last 
patient  died  of  perforation.  The  vomited  matters  are 
at  first  alimentary,  and  then  bilious.  Very  rarely  are 
they  feculent.  In  the  twenty  cases  there  are  only 
three  instances  of  stercoraceous  vomiting.  In  one 
case  it  appeared  on  the  fourth  day,  the  patient  dying 
on  the  seventh  ;  in  aiiother  instance  it  appeared  on 
the  sixth  day,  the  patient  dying  on  the  eighth  ;  in 
the  third  example  the  symptoms  were  very  acute,  the 
vomiting  was  incessant  and  soon  became  feculent, 
although  the  duration  of  the  attack  was  only  two 
days.  In  some  cases  the  vomiting  abated  considerably, 
or  was  even  absent  for  a  while.  As  already  stated, 
it  may  be  absent  at  first,  and  I  find  instances  where 
the  vomiting  did  not  commence  until  the  third,  fourth, 
fifth,  or  sixth  day  of  the  attack.  Li6baut  alludes 
to  a  case  where  vomiting  appeared  for  the  first  time 
on  the  eighth  day. 

Frequent  eructations  are  singularly  common  in 
this  form  of  obstruction. 

Constipation  exists,  as  a  rule,  from  the  first, 
and  is  absolute.  In  many  cases  scybala  have  been 
removed  by  enemata,  but  they  have  evidently  been 


Chap.  VII.]  Volvulus.  145 

derived  from  the  rectum  below  the  volvulus.  In  a 
few  instances  a  motion  has  been  passed  during  the 
progress  of  the  case,  as,  for  example,  on  the  second  or 
third  day.  In  one  case  scanty  motions  were  evacuated 
during  the  first  three  days  of  the  attack.  A  purge 
has  produced  a  slight  stool  after  the  symptoms  of 
vomiting  have  set  in,  but,  as  a  rule,  aperients  add  to 
the  severity  of  the  manifestations  of  the  malady,  and 
to  the  completeness  of  the  constipation.  In  these 
exceptional  cases  it  may  be  assumed  that  the  occlusion 
of  the  two  ends  of  the  loop  is  not  complete,  or  is, 
at  least,  not  complete  at  all  times.  The  scanty  stools 
that  may  be  passed  are  probably  derived  from  the 
contents  of  the  flexure  itself,  and  depend  upon  im- 
perfect closure  of  the  lower  end  of  the  loop,  the 
upper  end  being  still  entirely  occluded. 

Oeneral  conditioii.— When  the  symptoms  are 
severe  there  is  some  degree  of  collapse  established, 
although  it  is  seldom  so  marked  as  it  is  in  cases  of 
strangulation  by  bands.  It  depends  to  a  great  extent 
upon  the  suddenness  of  the  onset,  the  severity  of  the 
pain,  and  the  rapidity  of  the  progress  of  the  disease. 
In  two  instances,  where  the  patients  died  in  forty- 
eight  hours,  death  appears  to  have  been  due  to  a 
gradually  deepening  collapse.  In  any  case  there  is 
usually  great  prostration,  great  and  sudden  loss  of 
muscular  strength,  a  pinched  face,  sunken  eyes,  a  cold 
or  clammy  skin,  and  a  sensation  of  anxiety  and 
alarm. 

The  pulse  is  small  and  rapid  and  is  apt  to  soon 
assume  the  character  of  the  pulse  in  peritonitis. 

The  temperature  is  usually  below  normal  at  first, 
and  may  remain  so  until  death.  In  any  case  it  will 
probably  be  found  to  be  subnormal  until  peritonitis 
sets  in.  Even  when  peritonitis  occurs  no  appreciable 
rise  in  temperature  may  be  noted,  and  acute  perito- 
nitis has  been  found  in  the  autopsies  of  patients  who, 
K— 12 


146  Intestinal  Obstruction.        [Chap.  vii. 

throughout  the  whole  progress  of  the  attack,  never 
recorded  a  temperature  above  98-6.  As  a  rule,  how- 
ever, peritonitis  will  be  associated  with  an  increase  in 
the  bodily  heat,  an  increase  that  may  bring  it  up  to 
the  normal  level  or  a  little  above  it.  The  thermometer 
as  a  means  of  indicating  the  accession  of  peritonitis 
in  these  cases  is  of  little  value. 

The  respiraiions  are  usually  much  increased  in 
frequency,  a  symptom  that  depends  mainly  upon  the 
great  and  often  abrupt  distension  of  the  abdomen. 
Dyspnoea  has  in  many  cases  been  a  marked  feature, 
and  a  great  sense  of  suffocation  and  of  discomfort 
about  the  thorax  have  been  complained  of. 

As  will  be  pointed  out  below,  death  from  inter- 
ference with  the  functions  of  the  thoracic  organs  is 
not  infrequent  in  volvulus  of  the  sigmoid  flexure. 

The  tongue  is  coated,  and  often  much  coated ; 
being  at  first  moist,  and  then  usually  becoming  dry 
and  brown.  Great  thirst  is  not  usually  complained  of 
unless  there  has  been  severe  and  copious  vomiting  or 
much  collapse. 

In  the  acuter  cases  the  quantity  of  urine  is  as  a 
rule  diminished,  although  this  feature  is  not  so  marked 
nor  of  so  frequent  occurrence  as  it  is  in  cases  of 
strangulation  by  bands.  As  occurs  in  that  form  of 
obstruction,  so  in  this  ;  the  more  marked  the  pain  and 
collapse  and  evidences  of  general  constitutional  dis- 
turbance, the  more  likely  is  the  quantity  of  urine  to 
be  diminished,  while  under  the  influence  of  opium  the 
diminished  excretion  may  again  attain  to  its  normal 
proportions. 

In  only  one  case  in  the  series  of  twenty  does 
stranguary  appear  to  have  been  a  symptom.  In  this 
isolated  instance  the  patient  was  seized  on  the  second 
day  of  the  attack  with  such  a  very  frequent  desire  to 
urinate,  that  he  was  thought  to  have  cystitis.  He 
died  sixty-four  hours  after  the  appearance  of  the  first 


Chap.  VII]  Volvulus.  147 

symptom.  The  distended  sigmoid  flexure  was  found 
to  have  reached  the  diaphrai^m.  Ho  never  vomited 
except  to  reject  some  oil  he  took.  If  vomiting  is  in 
these  cases,  to  a  great  extent,  the  result  of  reflex 
nerve  disturbance,  it  would  appear  as  if  in  this 
instance  the  nerve  aj)paratus  of  the  bladder  had  been 
irritated  instead  of  that  of  the  stomach.  The  man 
might  almost  be  said  to  have  vomited  with  his  bladder 
instead  of  with  his  stomach. 

Tenesmus,  as  may  be  expected,  is  often  noticed  in 
volvulus  of  the  sigmoid  flexure.  In  three  of  the 
twenty  cases  alluded  to  this  symptom  was  very- 
marked,  incessant,  and  severe. 

Tlic  coiiclition  of  tlic  abdoiiBCii.— One  of 
the  most  conspicuous  features  in  volvulus  of  the 
sigmoid  flexure  is  the  enormous  distension  of  the 
abdomen.  This  distension  appears  very  early  and 
attains  very  considerable  proportions.  It  depends 
mainly  upon  the  dilatation  of  the  sigmoid  flexure  itself, 
although  there  is  much  distension  of  the  rest  of  the 
intestine.  The  i-apidity  with  which  the  meteorism 
develops  is  considerable.  In  patients  who  have  died 
in  sixty-four  or  sixty-eight  lioui's  the  twisted  liowel 
has  been  found  to  reach  the  diaijhragm,  and  has 
appeared  at  first  sight  to  occupy  the  whole  of  the 
abdomen.  The  swelling  is  usually  localised  at  first, 
appearing  as  a  rounded  elevation  in  the  left  segment 
of  the  umbilical  region,  and  then  occupying  the  whole 
of  that  region  together  with  the  epigastric.  In  the 
matter  of  locality,  however,  it  shows  much  variety."^ 
Very  soon  the  swelling  becomes  uniform  and  the 
abdomen  appears  as  evenly  blown  out  as  a  distended 
bladder. 

The  swelling  that  forms  early  in  the  case  may  be 

*In  one  case  at  least  the  swelling  was  most  conspicuous  in 
the  right  iliac  region.  The  twisted  gut  usually  passes  towards 
that  fossa  before  it  mounts  up  in  the  abdomen. 


148  Intestinal  Obstruction.       [Chap.vii. 

dull  over  some  part  of  its  extent  and  of  well  limited 
outline.  Such  was  the  case  in  a  patient  whose  history  is 
recorded  by  Mr.  Spencer  Watson.  Here  a  dull  rounded 
swelling  was  detected,  which  the  autopsy  showed 
depended  upon  a  volvulus  of  globular  outline  and 
about  the  size  of  a  child's  head.*  Much  thickening 
of  the  wall  of  the  volvulus  from  infiltration  would 
obviously  tend  to  diminish  its  resonance  on  percussion. 
Since  the  volvulus  always  extends  in  front  of  the 
other  intestines,  all  its  parts  must  be  more  or  less 
exposed  to  examination  through  the  parietes. 

The  abdominal  walls  are  at  first  more  or  less 
flaccid,  and  in  a  normal  condition  when  manipulated. 
As  the  distension  increases  they  become  of  course 
tenser,  and  as  the  peritonitis  advances,  more  and 
more  rigid. 

In  a  few  cases  the  movements  of  coils  of  intestine 
have  been  visible  through  the  parietes  before  the 
distension  had  reached  a  great  magnitude.  This 
visible  peristalsis  cannot  be  regarded  as  associated 
with  the  volvulus,  but  rather  as  due  to  a  long  con- 
tinued obstruction  in  the  bowels  upon  which  the  twist 
itself  had  probably  depended.  In  the  tAventy  cases 
alluded  to  I  have  met  with  only  two  instances  of  this. 
In  both  the  attack  came  on  gradually,  and  in  both 
there  was  a  history  of  long  continued  previous  con- 
stipation. One  of  the  patients  lived  seven  days,  the 
other  eight. 

I  know  of  no  instance  where  the  hand  has  been 
introduced  into  the  rectum  in  these  cases  for  the 
purpose  of  diagnosis.  If  such  manoeuvre  were  adopted 
there  is  no  doubt  but  that  the  obstruction  could  be 
felt. 

The  use  of  enemata  as  a  means  of  diagnosis  is  of 
much  value.  It  shows  that  tlie  bowel  will  hold  no 
more  fluid  than  a  rectum  could  accommodate,  and 
*  Med.  Times  and  Gazette,  vol.  ii.,  1879,  page  31. 


Chap.  VII.]  Volvulus.  149 

auscultation  would  demonstrate  that  the  injected 
matter  did  not  pass  the  region  of  the  sigmoid  flexure. 
It  is  said  that  about  one  and  a  half  litres  of  fluid  can 
without  diflS.culty  be  introduced  into  the  rectum 
alone. 

Course,  duration,  progriiosis.— Volvulus  of 
the  sigmoid  flexure  is,  so  far  as  is  known,  invariably- 
fatal  unless  relieved  by  surgical  interference.  The 
case  progresses  from  bad  to  worse,  as  a  rule  un- 
interruptedly, but  sometimes  with  remissions  in  the 
severity  of  the  symptoms. 

The  average  duration  of  the  attack  in  my  twenty 
cases  was  six  days.  The  longest  period  during  which 
the  patient  lived  was  twenty  days,  *  the  shortest 
sixty- four  hours,  f  Th  e  only  circum  stance  that  appears 
to  influence  the  rapidity  of  the  case  is  the  severity  of 
the  twist.  It  is  unafi'ected  by  the  age  of  the  patient 
and  by  the  preceding  symptoms.  The  cases  that  set 
in  abruptly  usually  display  the  most  rapid  course. 
In  the  patient,  however,  who  lived  twenty  days  the 
onset  was  sudden.  In  another  case,  on  tlie  other 
hand,  where  the  onset  was  gradual  the  patient  died  in 
three  days.  The  causes  of  death  in  the  more  rapid 
cases  are  collapse  and  interference  with  the  thoracic 
organs,  in  the  more  chronic  cases  peritonitis  and 
exhaustion.  The  two  patients  who  lived  for  the 
shortest  periods  (sixty-four  and  sixty-eight  hours 
respectively)  are  both  said  to  have  died  asphyxiated. 
In  cases  that  have  survived  for  a  longer  time  the 
fatal  issue  is  often  somewhat  sudden ;  and  here  it 
may  be  surmised  that  the  greatly  distended  flexure 
has  interfered  with  the  action  of  the  heart  or  lungs 
by  actual  pressure  through  the  diaphragm.  Before 
death  the  patient  has,  in   more   than   one  instance, 

*  Contrib.  a  1' Etude  de  I'Occlusion  intestinale,  by  Dr.  Le 
Moyne.  Paris,  1878. 

t  A  case  by  Melchiori  quoted  by  Dr.  Liebautin  his  monograph. 


150  Intestinal  Obstruction.       [Chap.  vii. 

complained  of  great  pain  in  the  chest  and  of  trouble 
in  the  cardiac  region.*  An  instance  of  sudden  death 
reported  by  M.  Potain  may  here  be  noticed.  A  man, 
aged  thirty-three,  who  had  been  long  troubled  with 
constipation,  was  admitted  into  hospital  wdth  simple 
obstruction.  His  bowels  had  not  been  relieved  for 
eight  days.  An  enema  merely  brought  away  a  few 
scybala.  His  abdomen  was  swollen,  but  it  was  neither 
tender  nor  painful.  He  had  not  vomited.  He  had  no 
dyspnoea.  The  morning  after  his  admission  he  was 
found  dead  in  his  bed.  His  decease  had  not  been 
observed  by  the  patients  lying  on  either  side  of  him 
in  the  ward.  The  autopsy  revealed  a  double  twist  of 
the  sigmoid  flexure  but  with  no  peritonitis.  The  gut 
was  fully  distended.  All  the  other  viscera  were 
healthy.  Two  patients  out  of  the  twenty  cases  died  of 
perforation  of  the  bowel  above  the  volvulus. 

There  is  no  evidence  to  show  that  a  volvulus  of 
this  part  can  ever  spontaneously  relieve  itself  when 
once  the  twist  is  well  established.  The  case  alluded 
to  above  of  a  patient  who  had  had  previous  attacks  of 
pain  with  obstruction,  and  who  on  each  occasion  but 
the  last  obtained  immediate  relief  by  assuming  a 
peculiar  posture,  suggests  a  possible  means  of  spon- 
taneous relief  in  slight  and  recent  cases.  When  the 
gut  has  become  twisted  it  is  conceivable  that  a  change 
in  the  patient's  position,  or  some  shifting  in  the 
position  of  the  irregularly  placed  contents  of  the  coil, 
or  some  unusual  movement  of  the  bowel  itself  may 
unwind  the  volvulus.  When,  however,  the  occlusion 
has  lasted  long  enough  to  allow  the  bowel  to  become 
distended  the  volvulus  is  almost  certain  to  be 
rendered  permanent. 

1  have  already  alluded  to  the  fact  that  when  the 
lower  part  of  the  sigmoid  flexure  or  the  upper  part  of 

* /S^ee  for  example  a  case  by  JVIi'.  Gay;  Path.  Soc.  Trans., 
vol.  X,,  page  153. 


Chap.  VII.]  Volvulus.  151 

the  rectum  become  suddenly  occluded  by  the  process 
known  as  kinking,  symptoms  may  be  induced  that 
precisely  resemble  those  of  the  present  form  of  ob- 
struction. I  have  mentioned  an  example  of  this 
where  all  the  symptoms  closely  resembled  those  of 
volvulus.  The  patient  was  middle-aged;  she  had 
been  troubled  with  constipation  for  some  time;  the 
onset  of  the  attack  was  sudden ;  swelling  of  the 
abdomen  was  rapid  and  marked;  the  pain  was  con- 
stant, with  exacerbations ;  the  vomiting  was  not 
severe  and  not  feculent ;  peritonitis  was  developing. 
The  rectum  had  been  closed  by  kinking  and  the 
sigmoid  flexure  filled  a  great  part  of  the  abdomen 
(page  108). 

(2)  The  toowel  is  intertWinecl  with  a  suit- 
able coil  of  small  intestine. — In  these  cases  the 
sigmoid  flexure  must  have  the  anatomical  arrangement 
described  in  the  preceding  paragraph,  i.e.  it  must  form  a 
long,  free  loop  with  a  narrow  pedicle.  The  loop  of 
small  intestine  should  possess  also  an  unnatural 
mobility,  and  should  have  an  unduly  long  and  narrow 
mesenteric  pedicle.  In  cases  where  two  such  coils 
have  become  intertv/ined  it  is  found  that  the  loop  of 
the  lesser  bowel  varies  in  length  from  four  to  twenty- 
one  inches,  while  that  of  the  sigmoid  flexure  measures 
from  twelve  to  forty  inches  (Leichtenstern).  The 
usual  mode  of  intertwining  is  as  follows  :  The  loop  of 
small  intestine  falls  in  front  of,  or  across,  the 
pedicle  of  the  sigmoid  flexure.  The  flexure  then 
winds  itself  around  the  axis  formed  by  the  lesser  coil. 
It  passes  upwards  in  front  of  the  loop  of  small  intestine 
and  then  moves  backwards  and  downwards  so  that  its 
free  end  passes  behind  the  pedicles  of  the  two  coils. 
In  this  way  the  abnormal  sigmoid  flexure  forms  a 
complete  turn  around  the  coil  of  lesser  intestine. 
Both  segments  of  the  bowel  become  strangulated,  but 
the  occlusion  will  be  most  severe  in  the  axial  loop. 


152  Intestinal  Obstruction.       [Chap.  vii. 

According  to  Leichtenstern,  this  variety  of  intertwin- 
ing occurs  in  more  than  one  half  of  all  the  cases 
belonging  to  this  species  of  volvulus.  Three  other 
methods,  however,  of  intertwining  occur.  In  one  the 
loop  of  ileum  lies  in  front  of  the  pedicle  of  the  sigmoid 
loop,  which  in  this  instance  forms  the  axis.  In  the 
remaining  two  cases  the  small  intestine  passes  behind 
the  pedicle  of  the  sigmoid  flexure,  when  the  loop  of 
ileum  may  form  the  axis  around  which  the  flexure  is 
entwined. 

In  all  these  examples  strangulation  is  very  severe, 
and  is  marked  by  great  vascular  engorgement  of  the 
involved  loops.  Such  engorgement  is  met  with  in  all 
cases  where  an  extensive  mesenteric  pedicle  is  pressed 
upon.  Not  only  are  the  walls  of  the  engorged  bowel 
infiltrated  with  blood,  but  much  haemorrhage  may  take 
place  into  its  cavity,  and  there  is  usually  an  abun- 
dant sero-sanguineous  exudation  into  the  peritoneal 
cavity. 

Leichtenstern  has  collected  no  less  than  twenty- 
one  examples  of  this  form  of  obstruction.  With  one 
exception  only  the  patients  were  all  males.  They 
were,  moreover,  all  adults,  the  ages  ranging  between 
twenty-four  and  seventy-three. 

The  syjiiptoms  that  attend  these  cases  are  those  of 
strangulation  of  a  very  acute  character.  The  onset 
is  more  or  less  sudden,  a  marked  degree  of  collapse  is 
soon  developed,  vomiting  is  incessant  and  profuse, 
there  is  great  pain  and  absolute  constipation.  The 
symptoms,  indeed,  are  those  incident  to  acute  strangu- 
lation of  the  small  intestine.  Diarrhoea  is  apt  to  pre- 
cede this  kind  of  incarceration  of  the  bowel,  and  a 
loose  stool  may  be  passed  after  the  onset  of  the 
symptoms.  It  is  evident  that  the  great  engorgement 
of  the  involved  coils  in  these  cases  would  lead  to  a 
copious  discharge  of  fluid  into  the  cavity  of  the 
intestine.     In   the   matter   of  diagnosis  it  would  be 


Chap.  VII.]  Vol  vvl  us.  153 

practically  impossible  to  distinguish  these  cases  from 
cases  of  strangulation  of  a  large  loop  of  intestine  by  a 
"  band,"  or  through  an  aperture. 

Death  is  very  rapid.  In  only  one  case  out  of  the 
twenty-one  just  alluded  to  did  the  patient  live  until 
the  sixth  day.  All  the  rest  died  within  the  first  two 
days,  and  many  within  the  first  twenty-four  hours. 

It  will  be  seen  from  this  that  the  present  form  of 
obstruction  constitutes  one  of  the  most  acute  forms  of 
strangulation  of  the  bowel  that  is  known. 

2.  Volvulus  of  the  ascending  colon  and 
csecum. — Volvulus  occurring  in  this  part  of  the  in- 
testine may  assume  a  variety  of  aspects,  and  is,  in  any 
case,  apt  to  adopt  a  very  complicated  arrangement. 

It  may  be  considered  under  three  categories.  (1)  A 
twist  of  the  ascendino-  colon  around  its  own  axis. 
(2)  Tmsts  brought  about  by  an  abnormal  loop  formed 
by  the  ascending  colon  and  caecum  with  a  long  and  dis- 
tinct meso-colon.  (3)  Twists  of  the  csecum  "upon 
itself  "  or  about  its  own  axis. 

(1)  Occlusion  of  the  bowel  may  be  brought  about 
by  a  twist  of  the  ascending  colon  around  its  own 
vertical  axis.  It  would  appear  that  this  condition 
may  be  found  in  a  colon  that  presents  no  anatomical 
abnormalities.  It  is  extremely  rare.  I  have  been 
able  to  find  but  one  distinct  instance  of  it.  This  was 
in  a  case  reported  by  Mr.  Curling.  The  patient  was 
a  man,  aged  twenty-seven,  who  was  attacked  with 
symptoms  of  intestinal  obstruction  that  ended  fatally 
in  eight  days."^  More  than  one  writer  on  intestinal 
occlusions  refers  to  this  variety  of  volvulus,  but  gives 
no  case. 

The  two  other  varieties  of  twist  met  with  in  this 

region  depend,  so  far  as  I  can  ascertain,  upon  certain 

congenital  abnormalities  in  the  bowel,  without  which 

neither  form  of  volvulus  could  have  been  possible.     I 

"*■  Path.  Soc.  Trans.,  vol.  ix.,  page  317. 


154  Intestinal  Obstruction.       [Chap.  vii. 

liave  collected  seven  cases  of  these  species  of  twist, 
and  in  every  instance  there  was  some  congenital  mal- 
formation of  the  parts  involved.  Before  considering 
the  matter  in  any  detail  it  would  be  well  to  take  a 
brief  glance  at  the  commoner  congenital  malforma- 
tions of  the  colon. 

In  the  foetus  the  small  bowel  occupies  at  one  time 
the  right  side  of  the  abdomen,  while  the  large  gut  is 
represented  by  a  straight  tube  that  passes  on  the  left 
side  vertically  from  the  region  of  the  umbilicus  to  the 
pelvis.  The  ca3cum  is  at  first  situated  within  the 
umbilicus,  and  tlien  ascends  in  the  abdomen  towards 
the  left  hypochondrium.  It  next  passes  transversely 
to  the  right  hypochondrium,  and  then  descends  into 
the  corresponding  iliac  fossa.  It  may  be  permanently 
arrested  at  any  part  of  its  course.  Thus  the  caecum 
may  be  found  about  the  umbilicus,  or  in  the  left 
hypochondriac  region  (the  ascending  and  transverse 
parts  of  the  colon  being  absent),  or  it  may  be  found 
in  the  right  hypochondrium,  the  ascending  colon  only 
being  unrepresented.  The  whole  of  the  large  intes- 
tine has  at  one  time  an  extensive  mesentery,  and  in 
some  rare  cases  this  condition  may  persist  throughout 
life.  It  will  be  seen  that  in  the  forms  of  volvulus 
now  to  be  noticed  certain  of  these  abnormal  conditions 
are  present. 

(2)  The  ascending  colon  and  caecum  may  be  pro- 
vided with  a  very  long  meso-colon,  as  long,  or  even 
longer  than  the  mesentery.  The  abnormal  coil  thus 
produced  is  very  apt  to  get  into  difficulties.  It  may 
become  twisted  about  its  own  mesenterial  axis,  just  as 
is  the  case  with  the  sigmoid  flexure.  An  instance  of 
this  is  recorded  by  Mr.  Avery.  Here  the  distended 
ascending  colon  formed  an  enormous  loop.  The 
patient,  a  man  aged  fifty-five,  died  after  nine  days  of 
almost  complete  obstruction.*  Left  lumbar  colotomy 
*Patli.  Soc.  Trans.,  vol.  ^ii.,  i^age  222. 


Chap.  VII.]  Volvulus.  155 

had  been  performed,  and  the  portion  of  gut  opened 
was  found  to  be  the  extremity  of  the  loop  formed  by 
the  ascending  colon. 

When  this  part  of  the  large  intestine  is  practically 
free,  and  has  a  large  and  long  mesentery,  it  may  form 
an  axis  around  which  a  suitable  coil  of  small  intestine 
may  be  entwined,  or,  on  the  other  hand,  it  may  itself 
wind  around  any  loop  of  the  lesser  bowel  that  is  in  a 
position  to  be  so  engaged.  The  arrangement  of  parts 
is,  indeed,  precisely  the  same  as  has  been  described  in 
connection  with  the  sigmoid  flexure.  The  latter  form 
of  volvulus,  where  the  large  gut  winds  round  the 
small,  is  the  more  common.  A  good  instance  of  it 
has  been  recently  placed  on  record.  In  this  case 
"  the  caecum  was  found  lying  under  the  diaphragm, 
close  to  the  spleen,  the  large  intestine  attached  to  it 
having  been  twice  twisted  round  the  lengthened 
mesentery  of  the  small  intestine,  causing  a  double 
obstruction."* 

The  symiotoms  in  these  cases  are  not  so  acute  as 
in  corresponding  examples  of  volvulus  implicating 
the  sigmoid  flexure.  In  Mr.  Firth's  case,  for  example, 
the  attack  began  with  sudden  pain,  followed  by 
vomiting,  which,  however,  did  not  become  severe  until 
the  next  day.  The  abdomen  became  distended  and 
tender,  and  the  bowels  absolutely  confined.  On  the 
fifth  day  laparotomy  was  performed,  but  the  obstruc- 
tion was  not  found.  Feculent  vomiting  commenced. 
On  the  evening  of  the  sixth  day  the  vomiting  abated 
and  ceased  to  be  stercoraceous.  On  the  seventh  day 
the  bowels  were  opened  eight  times.  The  patient 
became  gradually  worse,  and  died  collapsed  on  the 

*  Case  by  Mr.  Charles  Firth;  Brit.  Med.  Journ.,  vol.  ii.,  1882, 
IDage  166.  See  case  by  Dr.  Sands,  where  the  Ccecum  was  m  the 
right  hypochondrium,  and  where  the  mesentery  and  small  in- 
testine were  encircled  and  constricted  by  the  meso-colon.  jy-sw 
York  Med.  Record,  vol.  xxxi.,  1882,  page  427. 


156  Intestinal  Obstruction.       [Chap.  vii. 

eighth  day.  Perforation  of  the  csecum  had  occurred. 
There  was  commencing  general  peritonitis. 

(3)  In  this  variety  of  volvulus  the  caecum  has  been 
described  either  as  "  bent  upon  "  itself  or  as  twisted 
upon  itself.  The  difference  between  these  two  very 
similar  terms  is  really  greater  than  perhaps  the  terms 
themselves  would  permit.  In  the  former  instance, 
the  csecum  is  bent  about  a  line  at  right  angles  to  its 
long  axis.  The  result  is  that  the  lower  part  of  the 
caput  coli  is  found  in  front  of  the  ascending  colon, 
its  posterior  surface  becomes  anterior,  while  the  aj)- 
pendix  and  the  lowest  point  of  the  caecum  become 
uppermost.  At  the  angle  of  the  bend  there  is  of 
course  a  deep  crease  across  the  bowel,  and  by  the 
bendins:  in  of  the  mucous  membrane  at  this  crease  the 
lumen  of  the  gut  is  occluded.  Two  good  examples  of 
this  volvulus  have  been  described,  one  by  Dr.  Fagge,* 
the  other  by  Dr.  Handfield  Jones,  f 

In  the  other  variety  the  caecum  is  twisted  around 
its  own  long  or  vertical  axis  so  that  its  relations  to 
the  ascending  colon  are  practically  undisturbed. 
Three  examples  of  this  form  have  been  recorded  by 
Dr.  Fagge.J 

In  all  of  these  five  instances  of  volvulus  the 
caecum  presented  some  abnormality  that  may  be  safely 
regarded  as  congenital.  In  one  instance  it  was  found 
in  the  right  hyi)ochondrium,  in  another  in  the  left, 
in  a  third  example  it  occupied  the  pelvis,  and  in  a 
fourth  it  was  found  to  the  left  of  the  umbilicus.  In 
each  of  these  cases  the  ascending  colon,  or  the  gut 
that  should  represent  it,  presented  a  corresponding 
anomaly,  while  the  mal-placed  bowel  was  provided 
with  an  extensive  meso-colon. 

These  forms  of  twist  must  be  classed  among  the 

*  Guy's  Hosp.  Reports,  vol.  xiv, 

\Mtd.  Times  and  Gazette,  vol.  i.,  1872,  jjage  3. 

J  Guy's  Hosp.  Keports,  vol.  xiv. 


Chap.  VII.]  Volvulus.  157 

least  common  varieties  of  intestinal  obstruction.  Of 
the  mechanism  involved  in  their  formation  nothing- 
appears  to  be  known,  although  many  speculations 
have  been  vouchsafed  upon  the  subject. 

The.  symptoms  of  volvulus  of  the  caecum  vary  greatly, 
and  even  among  the  five  instances  just  alluded  to 
there  are  examples  of  an  acute,  of  a  subacute,  and  of  a 
chronic  case.  Four  of  the  patients  were  males,  one  a 
female.  Their  ages  ran  between  twenty-eight  and 
fifty-five.  The  fatal  attack  had  in  one  case  been 
preceded  by  severe  diarrhoea,  and  in  the  other  in- 
stances by  obstinate  constipation.  In  two  examples 
the  onset  may  be  said  to  have  been  sudden,  while  in 
the  remaining  cases  it  was  gradual.  Dr.  Jones' 
patient  was  seized  suddenly,  soon  after  a  meal,  with 
pain,  followed  by  vomiting  and  constipation.  On  the 
third  day  of  the  obstruction,  as  the  patient  was 
getting  out  of  bed  he  became  suddenly  collapsed  and 
died  in  a  few  minutes  of  syncope.  In  one  of  Dr. 
Fagge's  cases  the  attack  ended  fatally  in  three  and 
a  half  days.  In  another  case  the  attack  was  sub- 
acute. There  was  pain  which  subsided  once  and  then 
returned ;  constipation  which  yielded  once  and  then 
persisted;  vomiting  which  became  feculent  on  the 
twelfth  day  and  fsecal  shortly  before  the  patient's 
death  about  the  eleventh  day.  In  another  instance 
the  patient  died  four  months  after  admission  into 
hospital,  the  chief  symptom  during  that  time  being 
obstinate  vomiting.  In  one  other  patient  there  had 
been  severe  constipation  for  two  weeks,  but  vomiting 
did  not  set  in  until  the  day  before  death. 

The  symptoms,  therefore,  show  every  variation 
between  acute  obstruction  of  the  colon  on  the  one 
hand  and  chronic  or  partial  obstruction  on  the  other. 

Distension  of  the  abdomen,  often  of  an  irregular 
character,  was  constant.  In  all  cases  peritonitis  was 
found    at  the  autopsy.     The   caecum   was,    in   every 


158  Intestinal  Obstruction.       [Chap.  vii. 

example,  of  enormous  proportions.  In  one  case  it 
is  said  to  have  filled  nearly  one  half  of  the  abdomen, 
and  in  another  instance  to  have  apparently  occupied 
the  greater  part  of  that  cavity.  Once  it  is  spoken 
of  as  gangrenous,  and  in  two  instances  it  was  either 
ruptured  or  perforated. 

3.  Volvulus  of  the  small  intestine. — Twists 
of  this  part  of  the  bowel  may  be  considered  under 
two  categories.  In  one  a  loop  of  the  small  intestine 
is  twisted  about  its  own  mesenteric  axis,  in  the  other 
a  suitable  xjoil  or  loop  of  the  bowel  is  engaged  in  a 
volvulus  with  another  suitable  coil. 

(1)  A  volvulus  of  tJie  small  intestine  about  its 
mesenteric  axis. — Here  a  loop  of  the  bowel  is  twisted 
around  an  axis  represented  by  a  line  passing  along  the 
mesentery  from  its  root  at  the  spine  to  the  intestine. 
It  has  already  been  pointed  out  that  this  form  of 
twist  is  quite  common  in  cases  of  strangulation  by 
bands  and  through  apertures.  Many  instances  of  such 
strangulation  are  recorded  where  the  occlusion  of  the 
involved  bowel  has  been  brought  about  rather  by  its 
having  become  twisted  upon  itself  than  by  its  being 
actually  pressed  upon  by  the  band  or  by  the  margin 
of  the  aperture.  On  relieving  the  volvulus  by  per- 
forating the  bowel  the  gut  has  been  found  to  be  so 
lightly  held  that  the  slightest  degi'ee  of  traction  has 
served  to  reduce  it.  These  cases  are  often  associated 
with  evidences  of  incomplete  obstruction,  with  pain 
that  is  paroxysmal,  with  vomiting  that  is  irregular  in 
amount  and  intensity,  and  with  constipation  that  need 
not  be  absolute. 

Many  instances  also  may  be  alluded  to  where 
adherent  loops  and  coils  of  the  lesser  bowel  have 
become  so  twisted  upon  themselves  as  to  produce 
occlusion,  and  such  a  circumstance  has  often  given  an 
acute  ending  to  a  chronic  case. 

In  the  present  set  of  cases  the  gut  is  entirely  free 


Chap.  VI I .]  Vol  vul  us.  159 

from  adhesions  and  the  volvuhis  entirely  independent 
of  any  constricting  band.  The  condition  of  \\\q  intestine 
that  favours  twisting  is  identical  with  that  that  pre- 
disposes to  volvulus  of  the  sigmoid  flexure.  A  certain 
part  of  the  bowel  has  an  unduly  long  mesentery 
whereby  it  becomes  to  some  extent  separated  from  the 
remainder  of  the  intestine.  The  two  ends  of  the  coil 
so  individualised  are  brought  more  or  less  together,  so 
that  a  possible  pedicle  is  formed,  about  which  the  gut 
may  be  twisted.  This  condition  of  parts  may  be 
found  in  a  loop  of  ileum  that  has  long  been  herniated 
and  then  reduced.  The  approximation  of  the  two 
ends  of  a  coil  may  be  brought  about  by  mesenteric 
peritonitis  due  to  glandular  disease  or  to  other  causes. 
In  cases  where  the  elongation  of  the  mesentery  is  a 
conspicuous  feature  a  congenital  origin  may  probably 
be  ascribed  to  the  condition.  In  a  case  of  volvulus 
reported  by  Dr.  Fowler,  the  mesentery  of  the  involved 
coil  measured  from  seven  to  eight  and  a  half  inches 
from  its  root  to  its  attachment  to  the  bowel.*  The 
mechanism  of  the  volvulus  and  the  exact  means 
whereby  it  is  brought  about  are  still  matters  of 
speculation.  The  twist  is  usually  froin  left  to  right, 
and  as  a  rule  represents  one  complete  turn.  Fatal 
obstruction  may^  however,  follow  in  instances  where 
the  bowel  has  described  but  half  a  turn.f  Distension 
of  the  involved  coil  has  evidently  much  to  do  with 
the  volvulus.  In  two  or  three  instances  it  was  noticed 
at  the  autopsy  that  the  tAvist  became  spontaneously 
reduced  when  the  bowel  was  punctured,  but  reappeared 
when  it  was  again  inflated.  | 

The  general  appearance  of    a  simple  volvulus  of 

*  Lancet,  vol.  i.,  1883,  page  1119. 

t  See  case  by  Dr.  Sutton;  Brit.  Med.  Journ.,  vol.  i.,  1881, 
page  848. 

X  As  an  instance,  see  case  by  Dr.  Verneuil ;  Bull,  de  la  Soc. 
Anat,,  1870,  page  411. 


i6o  Intestinal  Obstruction.       [Chap.  vii. 

the   small   intestine  is  well  shown  in  Fig.   28  from 
a  specimen  in  St.  Thomas's  Hospital. 


Fig.  28.— Volvulus  of  lower  Ileum, 
a'  and  a2  join  one  another  after  many  convolutions. 

The  involved  coil,  being  closed  at  both  ends, 
becomes  greatly  distended.  This  distension  may 
cause  it  to  attain  huge  dimensions,   as  in  a  case  of 


Chap.  VII.]  Vol  vul  us.  i  6  i 

volvulus  of  the  duodenum  recorded  by  Dr.  Rombold, 
where  the  twisted  loop  looked  like  the  stomach,  and 
is  said  to  have  been  larger  than  an  adult's  head.  * 

The  walls  of  the  distorted  loop  are  deeply  con- 
gested, may  be  black  in  colour,  or  in  a  condition  of 
approaching  gangrene.  I  have  met  with  no  instance 
where  the  intestinal  wall  had  given  way  during  life. 

I  have  only  been  able  to  collect  ten  examples  of 
the  present  form  of  obstruction.  The  amount  of 
bowel  involved  varies  greatly.  In  the  majority  of 
the  cases  a  large  loop,  probably  about  one  foot  to  two 
feet  in  length,  is  implicated.  In  one  instance  five 
feet  of  bowel  were  discovered  to  have  been  twisted,  f 

As  regards  the  segment  of  the  bowel  involved,  in 
no  less  than  seven  cases  out  of  the  ten  the  volvulus 
was  in  the  lower  ileum.  In  the  three  remaining  cases 
the  twist  was  respectively  in  the  duodenum,  in  the 
upper  jejunum,  and  in  the  lower  jejunum.  Seven  of 
the  patients  were  males,  while  only  two  were  females. 
In  one  case  the  patient  is  merely  described  as  "  an 
infant."  The  average  age  of  nine  patients  (omitting 
the  case  of  the  infant)  was  twenty-three  years,  the 
youngest  individual  being  ten  years  old  and  the  oldest 
forty. 

The  symptoms  met  with  in  this  form  of  volvulus 
vary  considerably.  The  course  of  the  malady  may  be 
acute  or  chronic.  One  patient  out  of  the  ten  above 
alluded  to  exhibited  symptoms  of  partial  obstruction 
for  thirty-six  days,  while  another  was  troubled  with 
abrupt  attacks  of  obstruction  at  uncertain  intervals, 
for  more  than  a  year  before  death  occurred.  In  the 
remaining  eight  cases  the  average  duration  of  the 
attack  was  five  days,  the  extremes  being  thirty-two 
hours  and  nine  days. 

*  Oestreichische  Zeitschrift  fiir  prack.  Heilkunde,  1865.  N.  6. 
t  Dr.  James  Wilson ;  Amer.  Jour,  of  Med.  Sciences,  July,  1879, 
page  78. 

I.— 12 


1 6  2  JnTES  TINA L    ObS  TR  UC TION.  iChap.  VI  I. 

In  five  of  these  eiglit  cases  the  attack  came  on 
suddenly.  In  several  instances  no  cause  could  be 
assigned  for  the  intestinal  trouble.  In  other  cases 
diarrhoea,  or  less  frequently  constipation,  had  preceded 
the  symptoms  of  obstruction.  Pain  appears  to  be 
always  the  first  symptom  complained  of.  It  is  severe 
and  of  a  colicky  character,  and  at  first  usually 
localised  about  the  umbilicus.  As  the  case  progresses, 
and  probably  as  some  local  peritonitis  sets  in,  the  pain 
may  become  more  definitely  localised.  In  several 
examples  it  is  described  as  continuous  but  with 
exacerbations.  There  is  usually  no  tenderness  at  first, 
although  that  symptom  may  appear  before  the  termi- 
nation of  the  case.  It  depends  probably  upon  the 
development  of  some  peritonitis. 

Vomiting  appears  early.  It  is  a  marked  symptom, 
.but  would  seem  to  occur  rather  at  long  intervals  and 
in  large  quantities  than  to  be  incessant  and  less 
copious.  Out  of  the  eight  cases,  the  vomited  matters 
became  stercoraceous  in  two  instances,  in  five  instances 
it  is  described  as  non-stercoraceous,  and  in  the  re- 
maining case  all  description  is  lacking.  In  one  of  the 
cases  where  the  vomiting  was  non- feculent  the  duo- 
denum was  involved,  and  in  another  the  jejunum. 

Constipation  is  usually  complete  from  the  first. 
The  lower  bowel  may,  however,  be  emptied  by  enemata 
of  any  contained  faeces,  and  occasionally  a  motion  has 
been  passed  that  may  have  been  due  to  some  tempo- 
rary relaxation  of  the  volvulus.  The  abdomen  soon 
becomes  swollen,  and  an  indistinct  mass  or  tumour 
may  be  felt  within  if  the  twisted  bowel  be  of  good 
length  and  in  a  position  to  present  itself  beneath  the 
parietes.  Auscultation  during  the  administration  of 
an  enema  will,  as  a  rule,  demonstrate  readily  that  the 
colon  is  uninvolved.  In  one  case  where  the  lower  ileum 
was  implicated  the  patient  complained  of  severe  tenes- 
mus and  of  a  sensation  as  of  a  cord  encircling  the  body. 


Chap.  VII.]  Volvulus.  163 

Mr.  Harrison  Cripps  has  recorded  a  case  of  con- 
genital volvulus  of  the  ileum  that  is  probably  unique. 
The  child  had  had  no  action  of  the  bowels,  suffered 
from  obstinate  constipation  and  frequent  vomiting. 
Littre's  operation  was  performed  on  the  third  day  of 
life  under  the  impression  that  the  rectum  was  mal- 
formed. The  infant  died  of  peritonitis.  The  colon 
was  found  to  be  normal,  and  the  volvulus  to  be  slight 
and  very  readily  reduced. 

In  one  of  the  chronic  cases  (in  a  girl  aged  ten) 
the  attack  came  on  suddenly  with  intense  pain, 
vomiting  and  tenesmus.  The  acute  symptoms  soon 
subsided  and  the  case  became  chronic.  The  somewhat 
obstinate  constipation  was  interrupted  by  an  occasional 
stool,  the  vomiting  became  stercoraceous,  the  abdomen 
was  much  distended,  and  showed  through  its  parietes 
the  peristaltic  movements  of  the  bowels.  The  child 
was  much  emaciated,  and  died  at  the  end  of  thirty- 
six  days,  after  twenty-four  hours  of  intense  abdominal 
pain.  There  was  a  volvulus  of  the  lower  ileum  but 
no  peritonitis.*  In  the  other  chronic  case  the  patient 
had  no  less  than  seven  severe  attacks  of  obstruction  in  a 
little  more  than  twelve  months.  These  attacks  were 
somewhat  sudden  in  their  onset  and  associated  with 
constipation,  vomiting,  and  severe  pain.  They  were 
relieved,  as  a  rule,  at  the  end  of  a  few  days  by  means 
of  enemata,  the  patient  recovering  often  very  slowly. 
Here  the  volvulus  was  in  the  upper  end  of  the  jejunum. 
This  case  suggests  the  possibility  of  spontaneous  cure 
in  cases  of  volvulus,  and  it  may  be  that  several  of 
the  examples  of  acute  intestinal  obstruction  that  have 
either  ceased  spontaneously  or  yielded  to  some 
nostrum,  have  been  instances  of  volvulus  of  the 
lesser  bowel. 

Out  of  the  ten  cases,  acute  general  peritonitis  was 

*Dr.  Handfield  Jones;  Med.  Times  and  Gazette,  vol.  i.,  1872, 
page  3. 


164  Intestinal  Obstruction.         [Chap.  vii. 

met  with  in  four  instauces,  in  an  equal  number  of 
autopsies  the  serous  membrane  was  found  to  be 
healthy,  in  the  remaining  two  cases  its  condition  is 
not  described. 

Leichtenstern  describes  a  volvulus  that  implicated 
the  whole  of  the  jejuno-ileum.  As  I  have  been  able  to 
lind  no  other  cases  than  the  few  to  which  he  alludes, 
I  might  give  the  account  of  this  form  of  twist  in 
his  own  words  :  "  If  the  root  of  the  mesentery  be 
unusually  short,  while  its  height  and  the  length  of  the 
intestine  are  normal,  if  the  radix  mesenterii  runs 
more  vertically  than  usual,  if  the  mesentery  attains 
its  full  height  at  the  jejunum  suddenly,  and  loses  it 
just  as  abruptly  in  the  neighbourhood  of  the  caecum, 
then  the  small  intestine  is  in  a  condition  to  undergo 
twisting  as  a  whole  about  its  mesentery.  The  twist 
is  usually  180  degrees,  and  the  direction  such  that 
the  upper  end  of  the  intestine  is  carried  to  the  left 
and  downwards,  the  lower  end  to  the  right  and 
upwards.  The  right  side  of  the  mesentery  faces  to 
the  left,  and  the  left  to  the  right.  This  twist  does 
not  always  cause  absolute  occlusion,  often  only  a  con- 
striction at  each  end  of  the  twisted  convolution,  the 
beginning  of  the  jejunum  and  the  end  of  the  ileum, 
the  latter  of  which,  when  occlusion  takes  place,  is 
often  twisted  at  the  same  time  about  its  own  longi- 
tudinal axis.  Twisting  of  this  kind  has  been  seen  in 
very  young  children,  and  it  seems  as  if  that  variation 
in  the  development  of  the  mesentery  in  which  the 
ileum,  csecum,  and  ascending  colon  possess  a  common 
mesentery,  especially  disposed  to  it."  *  Dr.  Whipham 
reports  a  case  where  "  the  small  gut  with  the  caecum 
and  ascending  colon  were  attached  by  their  mesenteric 
envelopes  to  the  same  point  near  the  last  dorsal 
vertebra  ;  so  that  the  usual  attachment  of  the  colon 
to  the  right  iliac  fossa  was  deficient.  The  pedicle  of 
*  Loc.  cit. ,  page  565. 


Chap.  VI  I] 


Volvulus. 


165 


conjoined  mesentery  was  twisted  from  left  to  right 
across  and  around  tlie  union  of  the  duodenum  with 
the  jejunum,  so  as  to  compress  that  part  iirmly."  The 
jejunum  was  in  the  early  stage  of  gangrene.  The 
patient,  a  female,  aged  nineteen,  had  presented 
symptoms  of  intestinal  obstruction  for  twelve  days 
before  her  death.  She  suffered  from  severe  vomiting 
that  was  never  stercoraceous,  and  from  constipation 
that  was  relieved  once  during  the  twelve  days.  There 
was  no  swelling  of  the  abdomen  save  a  little  in  the 
epigastric  and  hypogastric  regions.  She  had  had 
previous  attacks  of  constipation  attended  with  colic 
and  sickness.* 

(2)  Two  suitable  coils  of  small  intestine  are  twisted 
together,  the  one  acting  as  an  axis  about  which  the 
other  is  wound.  The  suitability  consists  in  the  in- 
volved loop  being  possessed  of  a  long  and  narrow 
mesentery,  or  of  the  loop  that  forms  the  axis  being 
fixed  by  its  extremity  to  some 
point  on  the  parietes.  Such 
a  case  is  shown  in  the  ac- 
companying diagram  from 
Leichtenstern,  where  the  axial 
loop  was  adherent  to  the 
parietes  at  the  point  a  (Fig. 
29) ;  h  points  to  the  coil  that 
was  twisted  about  the  axial 
loop. 

This  form  of  volvulus  is 
very  rare.  It  would  appear 
that  the  symptoms  to  which 
it  gives  rise  are  of  an  acute 
character,  as  is  often  seen  in 
like  forms  of  volvulus  where  two  coils  of  bowel  are 
involved,  one  coil  being  composed  of  small  intestine. 

Dr.    Rundle    describes    an     autopsy    where     two 
*  Med.  Times  and  Gazette,  vol.  ii.,  1876,  page  33. 


Fiar.  29. — Volvulus  of  smnll 
lutestiues.    (Leiclitensteni). 


1 6  6  JnTES  TINA  L    ObS  TR  UC TION.  [Chap.  VIII. 

adjacent  coils  of  small  intestine  were  found  to  Le 
adherent,  while  around  them  a  third  segment  of  the 
lesser  bowel  had  become  twisted.  The  patient  was  a 
man,  aged  forty,  who  was  seized  with  sudden  and 
severe  abdominal  pain  associated  with  vomiting. 
Collapse  soon  appeared,  and  he  died  in  less  than 
twenty- four  hours.* 

Attention  has  already  been  drawn  to  cases  where 
a  volvulus  has  been  formed  by  an  intertwining  between 
a  loop  of  small  intestine  on  the  one  hand  and  the 
sigmoid  flexure,  or  an  abnormal  caecum  or  ascending 
colon,  on  the  other. 


CHAPTER    VIII. 

INTUSSUSCEPTION  :     PATHOLOGY. 

By  the  term  intussusception  is  understood  the  pro- 
lapse of  one  part  of  the  intestine  into  the  lumen  of  an 
immediately  adjoining  part.  In  cases  where  the 
extremity  of  the  ileum  is  protruded  through  the  ileo- 
cjBcal  valve  into  the  colon,  the  term  prolapse  is  singu- 
larly appropriate.  In  other  cases,  as,  for  example,  in 
intussusceptions  limited  to  the  small  or  to  tlie  large 
intestine,  the  condition  may  be  better  expressed  by 
saying  that  one  part  of  the  circumference  of  the 
bowel  has  been  turned  into  the  part  adjacent  to  it. 

Intussusception  is  a  very  common  form  of  intes- 
tinal obstruction.  Classing  all  varieties  of  obstruc- 
tion together,  it  forms  more  than  one-third  of  the 
whole.  Its  actual  share  is  probably  represented  by 
three-eighths.      Among    1,152  f   cases    of    intestinal 

*  Med.  Times  and  Gazette,  vol.  i.,  186G,  page  306. 
fFrom  this  collection  are  excluded  congenital  obstructions, 
stenoses  of  the  rectum  and  the  various  forms  of  hernia. 


Chap.  VIII.]     InTUSS  USCEP TION  :    Pa  THOL OGY. 


167 


obstruction  of  all  kinds  collected  by  Leichtenstern  are 
no  less  than  442  cases  of  intussusception.  In  a  special 
monograph  upon  the  subject  this  author  deals  with 
the  substantial  total  of  593  recorded  cases.* 

Patliolog'ical  anatomy. — If  an  intussusception 
be  viewed  in  vertical  section  it  will  be  seen  to  be 
composed  of  six  layers  of  intestine,  three  on  either 
side  of  the  central  canal,  all  more  or  less  parallel  to 
one  another.  It  will  be  noticed  also  that  the  arrange- 
ment of  the  layers  is  such  that  mucous  membrane  lies 
in  contact  with  mucous  membrane,  and  peritoneum 


c 


Ob"  \ 


a- 


Fig.  30. — Vertical  and  Transverse  Sections  of  an  Intussusception. 

o,  tbe  sheath  or  intussuscipiens  ;  5,  the  entering  or  inner  layer ;  c,  the  returning 
or  middle  layer. 


with  peritoneum.  On  horizontal  section  the  invagi- 
nated  mass  will  show  three  concentric  rings  of  bowel, 
with  of  course  the  same  mutual  relations  with  regard 
to  the  mucous  and  serous  surfaces  (Fig.  30).  All 
parts  of  the  intussusception  are  named,  and  the 
nomenclature  has  suffered  somewhat  from  an  exu- 
berance of  terms.  The  external  of  the  three  layers  is 
known  as  the  intussuscipiens,  the  sheath,  or  the  re- 
ceiving layer  (Za  gaine  of  the  French,  Fig.  30,  a). 
The  innermost  cylinder  is  known  as  the  entering  layer 

*  Vierteljahrschrift  f.  d.  prakt.  Heilk.    Prague,  1873-4. 


1 68  Intestinal  Obstruction.       [Chap.  vin. 

(Fig.  30,  6),  and  the  middle  one  as  the  returning  layer 
(Fig.  30,  c).  Taken  together,  these  two  layers  form 
the  intussusceptura  {le  boudin  of  the  French).  The 
"  neck "  of  the  intussusception  is  at  its  upper  part, 
where  the  returning  layer  joins  the  sheath  (Fig.  30,  a). 
The  ridge  formed  by  the  junction  of  these  two  layers 
is  known  as  le  bourrelet.  The  "  apex  "  of  the  intus- 
susception is  at  the  lower  part  of  the  intussiisceptum, 
where  the  entering  and  returning  layers  join.  The 
arrangement  of  the  various  parts  of  an  intussusception, 
are  well  shown  in  Fig.  31.  All  intussusceptions  are 
complete  in  the  sense  that  the  intussusceptum  is  com- 
posed of  all  the  coats  of  the  bowel,  and  that  it  enters 
the  sheath  evenly  and  equally.  Some  authors  have 
described  partial  or  lateral  intussusceptions.  In  these 
cases  a  polyp  exists,  and  by  a  dragging  upon  the 
tumour  the  part  of  the  intestinal  wall  to  which  it  is 
attached  is  drawn  into  the  lumen  of  the  gut,  so  as  to 
form  a  funnel-like  depression  on  the  surface.  Such 
invaginations  do  not  enter  into  the  present  category, 
and  I  have  been  unable  to  find  any  examples  of  them 
in  the  museums  of  London. 

Anatomical  varieties.  —  Invaginations  may 
occur  at  any  part  of  the  intestine  from  the  duodenum 
to  the  rectum.  They  may  be  conveniently  divided 
into  the  three  classes  :  (1)  the  enteric;  (2)  the  colic 
or  rectal ;  and  (3)  the  intussusceptions  that  involve 
the  ileo-c?ecal  segment  of  the  bowel. 

(1)  Enteric  invaginations  may  occur  in  any  part 
of  the  lesser  bowel.  In  the  upper  part  of  the  small 
intestine  they  are  rare,  although  an  isolated  case  or 
so  has  been  recorded  of  intussusception  of  the  duo- 
denum. They  are  most  common  in  the  lower  jejunum 
and  then  in  the  ileum. 

It  would  appear  that  jejunal  intussusceptions  bear 
to  ileic  intussusceptions  the  proportion  of  about  four 
to  one.     Invaginations  involving  the  small  intestine 


Chap. VIII.]   Intussusception :  Pathology. 


i6g 


seldom    attain   great    length.     They    are    often    very 
short,,  and   in  the    fliajority  of  cases  do  not  involve 


Fig.  31. — Intussixsceptioii  of  Jejiinnm. 
a,  internal  cylinder  ;  6,  middle  cylinder;  c,  external  cylinder. 

more  than  a  few  inches  of  the  bowel,  about  three  to 
ten  inches,  on  an  average.     Some  may  be,  however, 


170  Intestinal  Obstruction.       [Chap.  viii. 

of  considerable  length,  as  in  a  case  reported  by  Mr. 
Henry  Morris,  where  two  feet  of  the  lower  ileum  were 
involved ;  *  or  another,  recorded  by  M.  Bucquoy, 
where  over  two  yards  of  jejunum  were  implicated 
in  the  invagination.! 

Under  this  class  must  be  included  the  great  ma- 
jority of  "the  intussusceptions  of  the  dying." 

(2)  Colic  intussusceptions  present  many  varieties. 
Tlie  ascending  colon  may  be  invaginated  into  the 
transverse,  the  transverse  into  the  descending,  and 
the  descending  colon  into  the  sigmoid  flexure.  They 
are  most  frequently  met  with  in  the  two  last-named 
parts  of  the  colon.  Owing  to  the  comparative  fixity  of 
the  large  intestine,  it  happens  that  these  intussuscep- 
tions are  usually  short,  and,  indeed,  taken  as  a  whole, 
they  form  invaginations  that  in  point  of  size  are  the 
smallest  of  the  whole  series.  When  the  rectum  is 
involved  the  upper  segment  of  this  intestine  is  invagi- 
nated into  the  lower  part.  Such  intussusceptions 
must  of  necessity  be  short,  since  in  the  most  extreme 
cases  they  must  be  limited  by  the  length  of  the 
rectum  itself. 

(3)  The  intussusceptions  that  occur  in  the  ileo- 
csecal  region  may  be  divided  into  two  main  classes, 
the  ileo-csecal  and  the  ileo-colic. 

The  ileo-c9ecal  form  is  the  commonest  variety  of 
invagination,  while  the  ileo-colic  is  the  most  rare.  In 
the  former  the  ileum  and  csecum  pass  into  the  colon 
preceded  by  the  ileo-csecal  valve.  The  internal  cylin- 
der is  formed  of  the  termination  of  the  ileum ;  the 
external  cylinder  or  sheath  is  formed  by  the  colon 

'Path.  Soc.  Trans.,  vol.  xxviii.,  jiage  131.  See  also  case  by 
Mr.  Eager  (Lancet,  vol.  i.,  1882,  page  604),  where  one  and  a  half 
feet  of  the  upper  jejunum  were  involved. 

t  Recueil  des  Travaux  de  la  Soc.  Med.  d'Observ.,tome  i.,  page 
192.  Paris,  1857.  See  also  case  by  Dr.  Johnstone  of  Baltimore 
{Lancet,  vol.  i.,  1883,  page  176),  where  forty  inches  of  small  gut 
were  passed  by  the  anus,  with  recovery. 


Chap.  VIII.]  Intussusception:  Pathology.  171 

alone,  while  the  apex  of  the  intussusception  is  repre- 
sented by  the  ileo-csecal  valve.  This  form  may  attain 
great  size,  and  it  is  not  infrequent  for  the  valve  to 
traverse  the  whole  length  of  the  lai'ge  intestine  and 
ultimately  present  itself  at  the  anus  or  even  protrude 
through  that  sphincter. 

In  the  ileo-colic  variety  the  termination  of  the 
ileum  is  prolapsed  through  the  ileo-csecal  valve.  The 
valve  and  the  caecum  remain,  for  a  time  at  least,  in 
their  normal  situations.  The  apex  of  the  intussus- 
ceptum  must  always  be  formed  by  some  portion  of 
the  terminal  part  of  the  ileum.  This  intussusception 
is  commonly  associated  with  some  secondary  invagina- 
tion of  the  csecum  and  colon  itself,  concerning  which 
more  will  be  said  when  speaking  of  the  mode  of  in- 
crease observed  in  these  abnormal  conditions  of  the 
bowel.  A  third  variety  met  with  in  this  region  has 
been  termed  by  Leichtenstern  the  iliaca-ileo-colica. 
In  this  form  a  primary  intussusception  is  formed  in 
the  terminal  part  of  the  ileum.  This  invagination, 
when  it  reaches  the  valve,  may  either  pass  through  it 
(just  as  does  the  uninvaginated  gut  in  the  pure  ileo-colic 
form) ;  or  it  may  be  arrested  at  the  valve  and  then 
be  associated  with  an  invagination  of  the  csecum  into 
the  ascending  colon.  In  the  former  of  these  two  sub- 
varieties  the  apex  of  the  intussusception  will  be 
formed  of  ileum,  in  the  latter  it  will  be  represented 
by  the  ileo-csecal  valve. 

Relative  frequency  of  tlie  various  forms, 
— According  to  Leichtenstern,  whose  statistics  are  by 
far  the  most  numerous  at  present  published,  the  dif- 
ferent anatomical  varieties  are  thus  distributed  in 
one  hundred  cases:  Ileo-csecal,  44  per  cent.  ;  enteric, 
30  per  cent.  ;  colic  (including  rectal),  18  per  cent.  ; 
and  ileo-colic,  8  per  cent.  With  these  results  the 
statistics  published  by  Brinton  and  others  very  closely 
affree. 


172  Intestinal  Obstruction.       [Chap.  viii. 

Tlie  uiode  of  gi'owtli  of  tlie  iiitiissuscep- 
tion.  —  In  all  the  forms,  with  the  exception  of  the 
ileo-coHc,  the  method  of  increase  is  as  follows  :  "When 
an  intussusception  increases  in  length  after  a  piece 
of  bowel  has  been  primarily  invaginated,  the  in- 
crease is  at  the  expense  not  of  the  entering  layer,  but 
of  the  external  or  receiving  layer.  For  example,  let 
it  be  supposed  that  a  portion  of  the  termination  of 
the  jejunum  is  invaginated  into  the  ileum.  If  the 
mass  increases  in  length  it  will  do  so  solely  at  the  ex- 
pense of  the  ileum.  No  more  of  the  jejunum  will 
actively  enter  into  the  intussusception,  so  that  no 
matter  what  segment  of  gut  formed  the  original 
apex  of  the  intussusception,  that  apex  will  remain 
the  same  even  if  the  invagination  doubled  or  trebled 
its  original  length.  In  the  ileo-c^ecal  variety  the 
cjecum  is  turned  into  the  ascending  colon,  and  the 
valve  forms  the  apex  of  the  intussusception.  As  the 
invao:ination  increases  the  ascending  colon  becomes 
inverted,  then  the  transverse  and  descending  colon, 
until  at  length,  when  the  sigmoid  flexure  is  reached,  no 
trace  of  the  ascending,  nor  probably  of  the  transverse, 
colon  will  be  left,  but  the  valve  w^ill  still  form  the  tip 
of  the  intussusception.  It  is  ob%dous  that  in  the 
growth  of  this  variety  much  depends  upon  the  mobility 
of  the  colon,  and  since  the  colon  is  usually  much  less 
fixed  in  the  child  than  it  is  in  the  adult,  it  follows 
that  extensive  in^'aginations  of  this  species  are  most 
commonly  met  with  in  the  young. 

The  amount  of  traction  brought  to  bear  upon  the 
parts  in  growing  intussusceptions  that  involve  the 
colon  must  often  be  considerable.  This  is  well  illus- 
trated in  a  specimen  in  St.  Bartholomew's  Hospital.* 
It  shows  an  ileo-caecal  intussusception.  The  caecum, 
the  ascending  and  transverse  colon  have  disappeared 
from  view,  the  ileum  appears  to  enter  directly  into 
*  St.  Bart.'s  Hosp.  Museum,  No.  2,188. 


Chap.  VIII.]  Intussusception :  Pathology.  173 

the  descending  colon.  The  vermiform  appendix  and 
the  ileo-c?ecal  valve  project  beyond  the  anus.  By 
means  of  the  dragging  upon  the  transverse  colon  the 
stomach  has  been  rendered  vertical  and  has  been 
brought  into  close  contact  with  the  intussusception. 

In  the  ileo-colic  variety  the  method  whereby  the 
intussusception  increases  is,  in  the  first  instance  at 
least^  somewhat  different.  A  portion  of  the  terminal 
ileum  is  protruded  through  the  ileo-caecal  valve,  and 
the  invagination  may  increase  for  some  time  solely  by 
the  prolapse  of  more  and  more  ileum,  the  sheath  re- 
maining perfectly  unchanged.  This  is  exactly  the 
opposite  to  what  happens  in  other  intussusceptions. 
When  once  the  prolapse  has  commenced  no  obstacles 
are  offered  to  its  increase  other  than  those  presented 
by  the  resistance  of  the  valve  and  the  dragging  upon 
the  ileic  mesentery.  When  once  the  invaginated 
small  intestine  is  in  the  spacious  colon  it  meets  with 
practically  no  resistance.  Sooner  or  later,  however, 
no  more  ileum  can  become  prolapsed.  The  part  pro- 
truded may  become  fixed  by  adhesions  ;  or  from  con- 
gestion or  distension  of  the  ileum  the  valve  offers  a 
rigid  resistance  to  any  further  invasion  of  the  colon. 
In  such  a  case,  if  the  intussusception  still  continues  to 
increase  it  must  do  so  by  the  method  observed  in  other 
forms  of  invagination,  viz,  at  the  expense  of  its  sheath. 
No  more  ileum  can  enter,  but  the  caecum  can  be 
turned  in,  and  then  the  ascending  colon,  and  so  on 
until  at  last  the  rectum  may  be  reached.  A  good 
specimen  of  ileo-colic  intussusception  associated  with 
little  or  no  secondary  invagination  of  the  caecum  is 
shown  in  Fig.  32  from  the  Museum  of  the  College  of 
Surgeons.* 

The  iiitiissusception   of  the    dying^.  —  All 
invaginations   can  be  divided   into   two   great  forms 
according  to  the  circumstances  of  their  origin. 
*  No.  1,368  C. 


[Chap.  VIII. 


Fig.  32, — Ileo-colic  Intussusception. 
«>  SBcending  colon  ;  b,  ileum ;  c,  vermiform  appendix. 


Chap.  VIII.]     Intussusception :  Pathology.         175 

(1)  The  common  or  obstructive  intussusception 
and  (2)  the  intussusception  of  the  dying.  With  the 
former  only  is  surgery  concerned.  The  latter  is  a 
form  of  invagination  that  occurs  probably  a  little 
while  before  death,  and  depends  upon  certain  irregular 
peristaltic  movements  that  may  be  conceived  to  occur 
during  the  act  of  dying.  It  is  well  known  that  as  a 
patient  lies  in  articulo  mortis  muscular  actions  become 
often  irregular  and  disordered  before  they  cease  for 
ever.  It  is  consistent  with  experience  to  imagine  that 
a  like  feebly  tumultuous  action  may  pervade  the 
muscle  of  the  intestine  during  the  death  struggle,  and 
that  it  may  be  such  as  to  produce  some  invagination 
of  the  bowel.  Intussusceptions  of  this  kind  cause  no 
symptoms  during  life.  They  are  first  discovered  at 
the  autopsy.  They  are  always  very  small,  are  always 
free  from  any  trace  of  congestion  or  inflammation, 
and  interfere  little  with  the  lumen  of  the  bowel. 
With  the  most  trifling  amount  of  traction  they  can 
be  reduced.  They  are  most  usually  met  with  in 
children,  and  especially  in  such  as  have  died  of  brain 
disease.  They  occur  in  association  with  perfectly 
normal  abdominal  \dscera.  They  are  uncommon  in 
adults. 

In  two  other  points  may  they  differ  from  common 
intussusceptions,  viz.  in  number  and  in  direction. 
These  points  may  be  considered  in  more  detail.  The 
obstructive  invagination  is  usually  single :  the 
intussusceptions  of  the  dying  are  often  multiple. 
There  are  a  few  recorded  cases  where  several  intus- 
susceptions have  been  found  which  collectively  caused 
obstruction  and  which  were  apparently  not  of  the 
precise  nature  of  those  that  form  just  before  death. 
The  multiple  invaginations  are  always  small  and 
nearly  always  limited  to  the  small  intestine,  while 
at  the  same  time  they  are  associated  with  but 
slight  changes  in  the  gut.     The  common  obstructive 


176  InTES  TINA  L    ObS  TR  UCTION.  [Chap.  VIII. 

intussusception  that  is  associated  with  adhesion  of  its 
parts,  with  gross  changes  in  both  its  sheath  and  its 
intussusceptum,  and  often  with  gangrene  of  the  latter 
is,  so  far  as  I  can  ascertain  from  the  records  of  cases, 
invariably  single.  It  is  true  that  such  invaginations 
may  be  associated  with  others  that  are  secondary  to  it 
and  that  are  clinically  of  no  significance  ;  but  I  am 
aware  of  no  instance  where  two  obstructive  intussus- 
ceptions distinctly  independent  of  one  another,  and 
both  attended  by  such  morbid  changes  as  are  common 
in  such  invaginations,  have  existed  at  the  same  time 
in  the  same  body. 

The    intussusceptions    of   the    moribund,    on    the 
other  hand,  are  more  often  multiple  than  single.     It 


Fig.  33.— Intussusception  of  the  Dying. 

is  common  to  find  four  or  five  within  a  little  distance 
of  one  another,  and  even  as  many  as  ten  have  been 
met  with  in  a  single  case.* 

In  direction  the  obstructive  intussusception  is 
almost  invariably  descending,  i.e.  the  in-turning  of 
the  bowel  wall  is  in  the  direction  of  the  anus.  It  is 
true  that  a  primary  invagination  of  this  kind  may  be 
associated  with  a  secondary  ascending  intussusception. 

*  Dr.  Gee ;  Brit.  Med.  Jnurn. ,  Nov.  14 ,  1861.  See  also  Mr. 
Gay's  paper  on  Intussusception.     London,  1862. 


Chap. viii.]     Intussusception :  Pathology.  ijj 

But  such  secondary  formations  are  unimportant, 
have  little  or  no  influence  upon  the  primary  trouble, 
and  are  devoid  of  any  clinical  significance.  The  in- 
tussusceptions of  the  dying  are  often  ascending  or 
retrograde,  and  the  two  varieties  are  not  infrequently 
found  to  be  present  in  the  same  body.  A  specimen 
of  such  a  case  is  to  be  found  in  Guy's  Hospital,* 
while  Fig.  33  f  shows  the  common  appearance  of  the 
invaginations  of  the  moribund. 

These  non-clinical  intussusceptions  have  formed 
the  bases  of  many  erroneous  conclusions  and  have 
been  accredited  with  producing  an  obstruction  that 
may  have  existed  for  days  and  weeks  before  they 
themselves  had  any  existence.  A  case  reported  by 
M.  Leger  |  may  probably  be  an  example  of  this.  A 
woman  of  sixty-five  died  after  presenting  symptoms 
of  chronic  obstruction  that  had  extended  over  twelve 
months.  She  died  of  inanition.  The  autopsy  revealed 
an  intussusception  of  the  upper  part  of  the  jejunum 
18  cm.  in  length.  This  invagination  presented  no 
adhesions,  and  showed  an  absence  of  congestion  and 
indeed  of  any  other  morbid  changes  in  its  walls. 
It  is  extremely  improbable  that  this  intussusception 
could  have  induced  abdominal  symptoms  for  over 
twelve  months,  and  yet  after  death  be  found  to  be 
as  free  from  structural  changes  as  a  piece  of 
intestine  but  recentlv  invao-inated.  The  diagnosis  of 
chronic  intussusception  presupposes  that  the  invagina- 
tion had  existed  unreduced  for  the  period  covered  by 
the  symptoms.  Elsewhere  in  the  abdomen  were 
ancient  adliesions  the  products  of  a  past  peritonitis. 
It  would  probably  be  more  reasonable  to  assume  that 
the  chronic  obstraction  was  due  to  the  adhesions,  and 
that  the  intussusception  was  of  the  character  of  those 
that  form  when  the  patient   lies   in  articulo   mortis. 

*  No.  1,851  (42).     t  St.  Thomas's  Hosp.  Museum,  No.  E  2. 
I  Bull,  de  la  Soc.  Anat.,  1876,  page  719. 
M— 12 


I  7  8  IntES  TINA  L    ObS  TR  UC  TION.         [Chap.  VIII. 

Another  case  of  a  dijQTerent  nature,  reported  by  M.  Le 
idoyne,''^  may  possibly  fall  under  the  present  category. 
The  patient,  a  man  aged  thirty-five,  died  with  symp- 
toms of  subacute  obstruction.  The  autopsy  revealed 
six  intussusceptions  of  the  small  intestine.  They 
were  all  small,  readily  reduced,  and  free  from  any 
structural  or  vascular  changes.  The  sigmoid  flexure 
was  blocked  with  a  mass  of  fcecal  matter  and  un- 
digested food,  whicli  formed  so  large  a  collection  as  to 
produce  a  tumour  that  was  seen  through  the  parietes 
several  days  before  death.  In  this  instance  I  would 
venture  to  suggest  that  the  mass  in  the  colon  more 
probably  caused  the  fatal  obstruction  than  did  the 
intussusceptions  which  all  possessed  a  lumen  large 
enough  to  admit  the  point  of  the  little  finger. 

Retrog^rade,  double,  and  triple  intussiis- 
ceptioiiiS. — These  unusual  forms  may  conveniently 
be  considered  here.  It  has  been  already  said  that  the 
common  or  obstructive  invagination  is  almost  invari- 
ably descending  as  regards  its  direction.  To  this  ob- 
servation there  are  very  few  exceptions.  Out  of  a 
collection  of  593  cases  Leichtenstern  could  find  only 
eight  examples  of  a  primary  ascending  or  retrograde 
intussusception  of  the  obstructive  (or,  as  he  calls  it,  of 
the  inflammatory)  variety.  He  considers  that  these 
eight  instances  all  depended  upon  a  rare  association 
of  anomalous  circumstances,  and  regards  them  all  as 
allied  to  the  invaginations  of  the  death-struggle, 
among  which  retrograde  forms  are  by  no  means  un- 
common. A  case  or  two,  however,  of  retrograde  in- 
tussusception of  the  obstructive  variety  may  be  named 
that  would  appear  to  be  of  less  complicated  origin 
than  Leichtenstern  is  disposed  to  admit.  Such  a  case 
is  reported  by   M.   Besnier.f     It  concerns  a  female, 

*  Contrib.  a  I'Etude  des  Invaginations  de  I'Intest.  grele. 
Paris,  1879. 

\  Th^se  de  Paris,  1857,  page  52 


Chap .  V 1 1 1 .  ]      I  NT  USS  USCEP  TION  :   Pa  THOL  OG  V. 


179 


aged  22,  who,  after  presenting  symptoms  of  chronic 
obstruction,  died  after  nine  days  of  somewhat  acute 
manifestations.  The  autopsy  revealed  a  small  and 
simple  retrograde  intussusception  of  the  sigmoid  flexure 
into  the  descending  colon.  The  invaginated  layers 
were  secured  in  position  by  solid  adhesions,  and 
formed  in  the  lumen  of  a  gut  a  species  of  obstructive 
valve.  The  bowel  above  the  impediment  was 
ulcerated. 

A  primary  descending  intussusception  may  be 
associated  with  a  secondary  ascending  one,  the  two 
occupying  the  same  segment  of  the  bowel.  In  such 
cases  the  retrograde  invagination  is  external  to  the 
layers  that  take  a  descending  direction.  It  is 
extremely  probable  that  such  secondary  invaginations 
depend  upon  a  flaccid  and  plaited  sheath,  a  fold  of 
which  may  slip  up  between  itself  and  the  intussus- 
ceptum  and  so  produce  the  appearance  described"^ 
(Fig.  34).  It  is  significant  that  these  complicated 
forms  are  usually  met  witli  in 
the  colon.  An  arrangement  of 
sheath  that  would  favour  the 
complication  is  shown  in  Fig.  32. 
A  good  example  of  the  cases 
now  under  notice  is  reported  in 
a  recent  "  annotation "  in  the 
Lancet.  The  patient  was  a  child, 
aged  six  months,  who  died  with 
symptoms  of  intussusception  oc- 
curring after  an  attack  of  diar- 
rhoea. There  was  at  the  autopsy 
a  double  intussusception  of  the 
colon.  The  primary  invagination  was  downwards  and 
was  about  five  inches  in  length.  The  layers  composing 
it  were  adherent  and  deeply  congested.  The  retrograde 
intussusception  evidently  involved  the  sheath  after 
*  See  Leichtenstern  loc.  cit. ,  page  612. 


3  layers- "f^ 


5 tajers 
3layers^—\ 


Fig.  34. 


n 


iSo  Intestinal  Obstruction.      [Chap.  viii. 

the  manner  just  described.  It  was  about  half  the 
length  of  the  original  tumour  and  free  from  all 
adhesions.  Thus  the  involved  segment  showed  from 
above  downwards  first  three  layers  of  bowel,  then 
five  layers,  and  again  three  layers  (Fig.  34).  I  can 
find  no  recorded  case  that  would  support  the  state- 
ment of  some  to  the  efiect  that  a  descending  and  a 
retrograde  intussusception  may  start  from  two  points 
of  the  intestine,  remote  from  one  another,  and  then 
by  growing  ultimately  meet  and  inter-penetrate  one 
another. 

Instances  of  double  intussusceptions  are  fairly 
common.  In  these  cases  one  invagination  is  primary 
the  other  is  secondary.  The  primary  tumour  acts  as 
a  foreign  body  in  the  intestine  and  leads  to  fresh 
infolding  of  the  walls  of  the  bowel.  The  secondary 
invagination  concerns  only  the  sheath  or  receiving 
layer  of  the  primary  tumour.  This  variety  is  met 
with  both  in  the  colon  and  in  the  small  intestine,  and 
in  the  intussusceptions  of  the  dying  as  well  as  in  the 
obstructive  forms.  It  is  most  usually 
found  in  the  former  species  of  intus- 
susception. When  met  with  in  the 
obstructive  invagination  the  secondary 
layers  may  or  may  not  present  adhesions. 
Usually  they  are  free.  A  good  example 
of  a  double  intussusception  is  in  the 
London  Hospital  Museum.*  It  will  be 
obvious  that  such  invaginations  will 
present  five  layers  of  intestine  instead 
of  three  (Fig.  35). 
Cases  of  trijole  intussusception  are  not  so  common. 
Here  also  there  is  a  primary  invagination  and  then 
two  secondary  invaginations,  the  first  of  which 
involves  the  sheath  of  the  primary  intussusception. 
In  these  cases  it  will  be  evident  that  the  tumour  will 
*  Lond.  Hosp.  Museum,  No.  25. 


Fig.  35. 


Chap.  VIII.]    Intussusception:  Pathology. 


I5I 


present  no  less  than  seven  layers  of  intestine,  as  can 
be  seen  in  the  annexed  diagram  (Fig.  36).  An 
excellent  example  of  this  variety  is  described  with 
great  clearness  by  Bucquoy.'^  It  was  met  with  in 
a  male  patient,  aged  twenty-two,  who  died  after 
having  presented  the  symptoms  of 
chronic  intussusception  for  about  six 
weeks.  For  many  months  preced- 
inof  the  onset  of  the  final  attack  he 
had  had  somewhat  similar  seizures, 
but  of  slighter  character  and  of 
short  duration.  Both  the  terminal 
attack  and  one  of  the  previous 
seizures  were  associated  with  the 
appearance  of  a  very  distinct  ab- 
dominal tumour.  The  post-mOrtem  I  (J  I 
inspection  revealed  a  triple  intus- 
susception that  involved  nearly  the 
whole  of  the  jejunum.  The  tumour 
formed  was  eleven  and  a  half  inches 
loncf  and  six  inclies  in  circumfer- 
ence,  and  presented  seven  layers  of 
intestine. 


Fig.  36. 


THE    GENERAL    PATHOLOGICAL    CHANGES    IN    AN 
INTUSSUSCEPTION. 

1.   The  part  played  by  the  mesentery.— As 

an  invagination  increases  it  is  obvious  that  the 
mesentery  must  be  drawn  in  with  the  bowel.  In  a 
tumour  of  any  magnitude  it  is  found  between  the 
two  layers  of  the  intussusceptum,  drawn  out  into 
the  form  of  a  cone,  with  its  apex  at  the  extremity 
of  the  intussusception  and  its  base  at  the  neck. 
As  the  invagination  increases  the  traction  upon  the 

*Recueil  des  Travaiix  de  la  Soc.  Med.  d'Observ.,  page  192. 
Paris,  1857. 


1 8  2  InTES  TINA  L    ObS  TR  UC  TION.         [Chap.  V 1 1 1 . 

mesentery  must  be  great.  In  cases  of  extensive 
intussusception  it  may  be  well  imagined  that  that 
traction  is  often  considerable.  For  instance,  the 
ileum  with  its  mesentery  may  be  inverted  into  the 
caecum,  and  may  travel  along  the  whole  length  of  the 
colon,  until  it  presents  or  even  protrudes  at  the  anus. 
It  is  obvious  that  in  such  cases  the  mesentery  must 
be  either  unduly  long  or  must  have  been  greatly 
stretched.  The  increased  length,  however,  required 
in  the  mesentery  to  permit  its  appeai'ance  at  the  anus 
is  not  so  considerable  as  may  at  first  sight  appear. 
As  the  prolapsed  gut  travels  from  the  ctecum  to  the 
anus  it  practically  describes  a  circle.  The  centre  of 
this  circle  may  be  taken  as  the  vertebral  attachment 
of  the  mesentery,  and  the  radii  of  the  circle  as 
represented  by  the  mesentery  itself.  The  distance 
between  the  involved  bowel  and  the  mesenterial 
centre  is  not  greatly  increased  as  the  prolapsed  part 
passes  along  the  colon.  Indeed,  the  greatest  demand 
upon  the  length  of  the  mesentery  is  made  by  the 
dragging  of  the  membrane  into  the  narrow  tube  of 
the  intussusception. 

The  fact  that  an  ileo-caecal  or  ileo-colic  intussuscep- 
tion may  be  felt  in  the  rectum  within  comparatively 
a  short  time  of  its  formation  will  show  that  the 
elongation  of  the  mesentery  need  not  be  considerable, 
even  if  allowance  be  made  for  congenital  super- 
abundance. 

The  traction  exercised  by  the  mesentery  has  a 
considerable  effect  upon  the  tumour.  It  bends  the 
intussusception  so  that  it  becomes  curved  in  outline, 
the  concavity  of  the  curve  being  towards  the 
mesenterial  attachment.  Sometimes  the  bending  is 
considerable  and  almost  angular,  while  a  deep  trans- 
verse fold  forms  across  the  concavity  of  the  cylinder 
of  the  intussusceptum.  This  altered  outline  is 
communicated   in    a    much    diminished    form    to   the 


Chap. VIII.]     Intussusception:  Fatholqgv.  183 

investing  layer,  and  thus  the  whole  tumour  has  a 
tendency  to  assume  a  curved  outline.  The  concavity 
of  this  curve  looks  towards  the  root  of  the  mesentery. 
As  another  result  of  the  traction,  it  happens  that  the 
axes  of  the  intussusceptum  and  intussuscipiens  do  not 
correspond.  The  former  does  not  lie  in  the  axis  of 
the  latter,  but  is  placed  eccentrically  nearer  to  the 
mesenteric  border  of  the  bowel.  It  follows  also  that 
the  orifice  of  the  intussusceptum  is  made  to  assume  the 
aspect  of  a  slit,  and  looks  not  so  much  towards  the 
lumen  of  the  bowel  below  as  towards  the  mesenteric 
side  of  the  receiving  layer. 

The  extent  of  these  changes  varies  considerably. 
They  may  be  entirely  absent,  especially,  as  Leichten- 
stern  remarks,  in  intussusceptions  of  the  middle  part 
of  the  ileum.  They  are,  perhaps,  best  seen  in  the 
invaginations  of  the  ileo-ceecal  region. 

In  the  colon  the  meso-colon  may  play  somewhat 
the  same  part  as  the  mesentery.  In  colic  intussuscep- 
tions, however,  it  is  very  common  to  find  the  various 
layers  of  the  mass  parallel  to  one  another,  the 
aperture  in  the  centre  and  directed  towards  the 
central  axis  of  the  gut  below.  On  the  other  hand, 
several  museum  specimens  show  that  the  intussus- 
ceptum may  be  as  curved  in  a  colic  invagination  as  it 
is  in  any  enteric  form  of  the  affection.  Such  a 
specimen  is  shown  in  Fig.  ST,"^  where  the  descending 
colon  has  become  invasdnated  into  the  sio-moid  flexure. 
As  an  example  of  a  straight  or  non-curved  intussus- 
ception of  tlie  colon,  I  might  cite  a  specimen  in  the 
London  Hospital,  f 

Intussusceptions  of  the  rectum  are  all  more  or 
less  free  from  curving.  \ 

*  St.  Thomas's  Hosp.  Museiim,  No.  R  12 
t  No.  Ae.  47. 

X  As  examples  see  Coll.  of  Surgeons  Museum,  Nos.  1,380  and 
1,380a. 


1 84 


.Intestinal  Obstruction.      [Chap.  viii. 


Fig.  37.— Intussusception  of  descending  Colon  into  Sigmoid  Flexure. 

a,  the  sheath. 
There  is  great  thickening  of  the  intussusceptum,  especially  on  its  convex  Bide. 


Chap. VIII.]    Intussusception :  Pathology.  185 

2.  How  obstruction  aiitl  sti'aiig:iilatioii 
are  produced. — Mere  invagination  of  the  bowel 
need  not,  by  any  means,  lead  of  necessity  either  to 
strangulation  of  the  involved  part  or  to  complete  or 
even  serious  obstruction  to  the  lumen  of  the  intestine. 

Many  cases  are  recorded  where  the  patients  have 
lived  for  months,  presenting  evidences  of  the 
abdominal  disturbance,  and  have  died  without  ever 
displaying  the  symptoms  of  strangulation  or  acute 
obstruction  of  the  bowel.  At  the  autopsies  made 
upon  such  patients,  the  intussusception  that  caused 
death  has  often  been  found  to  show  none  but  the 
most  insignificant  structural  changes  and  to  be 
perfectly  reducible.  As  one  instance  I  might  quote 
a  case  of  Dr.  Brinton's,  the  case  of  a  man  who  died 
of  chronic  intussusception  lasting  over  four  and  a 
half  months.  The  post-mortem  revealed  an  ileo- 
csecal  invagination  quite  free  from  any  gross  local 
changes."^  There  is  also  Mr.  Hutchinson's  oft-quoted 
case  of  a  child,  aged  two,  who  had  suffered  from 
chronic  intussusception  for  one  month.  At  the  end 
of  that  time  Mr.  Hutchinson  opened  the  abdomen, 
and  readily  reduced  the  invagination  he  found  therein. 
The  patient  recovered.!  Many  other  examples  could 
be  given.  Such  cases,  however,  are  exceptional. 
More  usually  the  compression  of  the  involved 
mesentery  and  the  manner  in  which  it  is  dragged 
upon  lead  to  some  obstruction  of  its  vessels.  The 
veins  would  be  more  especially  involved,  the  return 
of  blood  from  the  inturned  gut  would  be  prevented, 
and  as  a  result  the  intussusceptum  would  become 
engorged  and  swollen.  It  is  to  be  noted  that  this 
interference  with  the  circulation  is  of  the  very  kind 
that  tends  to  produce  irregular  movements  in  the 
intestine.     The  part  indeed  may  become  strangulated, 

*  Lancet,  vol.  i.,  1863,  page  409. 
tMed.-Chir.  Ticans.,  vol.  xxxvii.,  1874. 


1 86  Intestinal  Obstruction.      [Chap. viii. 

and  as  a  result  the  whole  of  the  intussusceptum  may 
become  gangrenous.  The  intussusceptum  is,  in  fact,  in 
the  position  of  a  strangulated  hernia  involving  a 
knuckle  of  bowel. 

Speaking  generally,  therefore,  it  may  be  said  that 
patients  with  intussusception  may  die  of  one  of 
two  principal  causes.  They  may  die  of  strangulation 
of  the  bowel  and  its  results,  or  they  may  gradually 
waste  and  die,  worn  out  by  long-continued  pain 
and  sickness  and  other  effects  of  narrowing  of  the 
bowel.  Chronic  cases  very  often  terminate  with 
acute  strangulation. 

The  actual  obstruction  to  the  passage  of  matters 
along  the  intestine  may  be  brought  about  in  many  ways. 

(1)  The  orifice  of  the  intussusceptum  is  rendered 
slit-like  by  the  dragging  of  the  mesentery,  and  may 
be  opposed  to  the  wall  of  the  receiving  layer. 

(2)  The  intussusceptum  may  be  so  bent  or  curved 
upon  itself  as  to  greatly  narrow  the  lumen  of  the 
inner  cylinder.  This  is,  to  some  extent,  shown  in 
Fig.  37. 

(3)  The  considerable  thickening  that  the  tunics 
of  the  involved  bowel  undergo,  as  the  results  of  con- 
gestion, exudation,  and  inflammation,  tend  to  greatly 
narrow  the  lumen  of  the  passage.  So  extreme  may 
the  narrowing  from  this  cause  alone  be  that  it  may 
reduce  the  calibre  of  the  central  canal  to  that  of  a 
No.  10  or  No.  12  catheter. 

(4)  The  already  narrowed  passage  may  be  finally 
occluded  by  some  accidental  circumstance.  Thus  Mr. 
Gay  mentions  a  case  of  ileo-csecal  intussusception 
where  the  valve  was  found  to  be  blocked  by  some 
undigested  rice.*  In  other  instances  the  central  canal 
has  been  plugged  by  blood  clots,  f    In  at  least  one  case 

*  On  Intestinal  Obstruction  by  Invagination.     London,  1862. 
-^ Lancet^  vol.  ii.,  1846,  page  88 ;  and  Path.  Soc.    Trans.,  vol. 
xxviii.,  1877,  page  131. 


Chap. VIII.]    Intussusception :  Pathology.  187 

the  polyp  that  caused  the  intussusception  finally 
blocked  entirely  its  lower  aperture,"^  and  it  has  been 
said  by  Dr.  Brinton  that  an  obstruction  may  be  pro- 
duced by  a  gangrenous  intussusceptum  after  it  has 
separated,  f 

3.  HoAv  tlie  iiivag:iiiation  becomes  ii're- 
ducible.— This  is  a  matter  of  extreme  importance  in 
the  prognosis.  If  the  intussusceptum  is  irreducible, 
then  cure  by  spontaneous  reduction  is  impossible,  as 
is  also  reduction  by  means  of  forcible  enemata  or  by 
laparotomy.  On  the  other  hand,  if  the  tunics  of  the 
mass  be  glued  together  by  adhesions  about  the  neck 
the  pai-ts  are  most  favourably  placed  for  spontaneous 
recovery  by  elimination  of  the  gangrenous  intussus- 
ceptum. 

The  irreducibility  very  commonly  depends  upon 
adhesions.  Peritonitis  is  excited  in  the  invaginated 
mass,  and  the  serous  coats  of  the  inner  and  middle 
layer  become  glued  together,  while  more  extensive 
adhesions  involving  also  the  external  coat  may  occur 
about  the  neck  of  the  tumour.  The  situation  of  the 
adhesions  varies.  Sometimes  they  are  limited  to  the 
neck  of  the  mass,  at  other  times  to  its  apex,  while  in 
a  third  class  of  case  they  involve  the  whole  length  of 
the  inner  and  middle  layers.  On  the  whole,  the  last 
named  are  the  most  common,  although  adhesions 
limited  to  the  neck  of  the  intussusception  are  prob- 
ably the  more  usual  in  acute  cases.  Adhesions  occur- 
ring only  at  the  actual  apex  of  the  intussusceptum  are 
certainly  the  least  frequently  met  with. 

In  any  case  the  false  bands  may  vary  from  a  few 
insignificant  fibres  to  a  dense  membrane  closely  binding 
together  the  opposed  layers. 

In  extensive  invaginations  it  is  common  to  find 
the  first  few  inches  of  the   intussusception  fixed  by 

*M.  Fernet;  Bull,  de  la  Soc.  Anat.,  1863,  page  296. 
t  Intestinal  Obstruction.     London,  1868. 


1 8  8  InTES  TINA L    ObS TR  UCTION.         [Chap.  VIII. 

adhesions  while  the  remainder  is  quite  free.  In  these 
cases  it  is  probable  that  the  adherent  parts  represent 
those  first  invaginated,  no  adhesions  forming  between 
the  layers  subsequently  prolapsed.  Thus  it  happens 
that  the  whole  intussusception  can  be  readily  reduced, 
with  the  exception  of  the  last  inch  or  so. 

Of  the  circumstances  that  influence  the  formation 
of  these  adhesions  little  is  known.  Their  appearance 
is  most  uncertain.  They  may  be  absent  in  a  case  that 
has  lasted  for  months  and  present  in  one  of  but  a  few- 
days'  duration.  Putting  aside,  however,  exceptional 
cases  it  would  appear  that  the  element  of  time  has 
the  most  marked  eifect  upon  this  occurrence.  In 
examples  of  chronic  intussusception  adhesions  are  the 
rule.  They  are  present  in  about  80  per  cent,  of 
the  cases.  In  acute  invaginations  adhesions  are  as 
often  absent  as  present.  Indeed  they  would  appear 
to  be  mnore  often  absent  than  present,  for  an  examina- 
tion of  nearly  sixty  recorded  instances  of  the  acute 
form  that  I  have  collected  myself  shows  the  presence 
of  adhesions  in  about  45  per  cent,  only  of  the 
cases."*  The  earliest  time  for  the  appearance  of  defi- 
nite adhesions  is  the  third  day.  It  is  needless  to 
observe  that  recent  adhesions  are  very  soft  and  yield- 
ing, so  that  in  acute  examples,  although  false  liga- 
ments may  exist,  yet  they  need  not,  in  themselves, 
offer  any  serious  obstacle  to  attempts  at  reduction. 

Irreducibility,  however,  may  depend  upon  other 
causes  than  the  results  of  local  peritonitis. 

(1)  The  swelling  of  the  intussusceptum  may  be  so 
excessive  as  to  entirely  prevent  reduction.  "Very 
often  the  swelling  is  most  marked  near  the  apex,  so 

*  These  statistics  include  cases  of  recovery  without  operation 
where  the  reduction  of  the  mass  was  effected  by  artificial  means. 
The  figxires  are  probably  fallacious.  Cases  free  from  adhesions  are 
obviously  the  most  likely  ones  to  yield  to  treatment,  and  thus  to  be 
placed  on  record.  An  examination  of  museum  specimens  places 
the  nimiber  of  cases  where  adhesions  exist  iu  a  higher  i^ercentage. 


Chap.  VIII.] 


189 


Fig.  38.— Ileo-caecal  Intussusception  with,  great  swelling  of  the  Intu9- 

susceptum. 


1 90  Intestinal  Obstruction.        [Chap. viii. 

that  the  inner  cylinders  present  at  their  extremities 
a  huge  knob  that  would  withstand  all  attempts  to 
replace  the  parts.  A  good  example  of  this  is  afforded 
in  Fig.  38.* 

(2)  Since  the  swelling  and  thickening  of  the  coats 
are  most  apt  to  affect  the  convexity  of  the  intiissus- 
ceptum  it  happens  that  so  curved  an  outline  is  often 
given  to  that  part  and  so  great  an  alteration  effected 
in  its  density  that  reduction  is  for  this  reason  also 
quite  impossible.      {See  Fig.  37.) 

(3)  The  invaginated  bowel  may  become  peculiarly 
twisted  and  may  on  this  account  be  rendered  irredu- 
cible. Thus  Mr.  Royes  Bell  performed  laparotomy  on 
the  fifth  day  in  a  case  of  intussusception.  There  were 
practically  no  adhesions,  yet  the  mass  was  so  twisted 
that  all  attempts  at  reduction  failed.  In  this  instance 
the  colon  was  involved.!  In  Fig.  39,  from  University 
College  Museum,  a  specimen  of  a  twisted  intussuscep- 
tion is  shown  that  only  implicated  the  ileum.  \ 

(4)  In  ileo-colic  invaginations  an  especial  obstacle 
to  reduction  is  offered  by  the  ileo-csecal  valve,  which 
tightly  grips  the  prolapsed  gut  and  induces  in  it  a 
rapid  engorgement. 

(5)  When  a  polyp  exists  at  the  apex  of  the  intus- 
susceptum,  it  forms,  when  associated  with  swelling  of 
the  gut  above  it,  a  very  definite  impediment  to  reduc- 
tion. This  is  well  illustrated  in  the  specimen  from 
which  Fig.  40  is  taken.  § 

4.  Changes  in  the  gnt  above.— The  bowel 
above  the  intussusception  shows  in  acute  cases  no 
gross  changes  other  than  those  of  dilatation  and  con- 
gestion. In  chronic  forms,  however,  its  walls  are 
usually  hypertrophied,  and  in  some  instances  this  hy- 
pertrophy has  attained  considerable  dimensions. 

*  St.  Thomas's  Hosp.  Museum,  No.  R  8. 

\  Lancet,  vol.  i.,  1876,  page  ]2.  J  No.  1,176. 

§  Coll.  of  Surgeons  Museum,  No.  1,378. 


Chap.  VIII.] 


191 


Fig.  39. — Intussusception  of  Ileum. 
a,  Intussusceptum. 


192 


Intestinal  Obstruction.      [Chap.  viii. 


Great  faecal  accumulation  above  the  invagination 
is  rare  in  any  case,  the  lumen  of  the  bowel  being 
usually  sufficiently  patent  to  allow  of  the  passage  of 


Fig.  40. — Intussusception  of  Ileum. 

A  firm  oval  tumour  exists  at  the  end  of  the  intussusception, 
the  lumen  of  the  gut. 


A  bougie  indicates 


matters  for  at  least  some  time.  Ulceration  of  the  in- 
testine above  the  involved  segment  is  comparatively 
rare,  and  is  somewhat  more  common  in  chronic  than 
in  acute  cases.  Perforation  may  occur  as  a  result  of 
this  ulceration.  In  at  least  two  instances  the  bowel 
above  the  invagination  underwent  spontaneous  rup- 
ture.    Both  cases  were  more  or  less  chronic,  were  in 


Chap.  VIII.]  Intussusception :  Pathology.  193 

males  and  adults.  In  one  example"^  the  ileum  had 
ruptured  above  an  ileo-ciecal  invagination;  in  the 
other t  the  rent  was  found  in  the  middle  of  the  ascending 
colon,  the  intussusception  being  limited  to  the  rectum. 

5.  Changes  in  the  iiitiissuscipieiis.— The 
sheath  or  receiving  layer  seldom  shows  any  gross 
changes.  It  may  be  congested,  or  a  little  thickened. 
It  may  be  much  Avi'inkled  and  thrown  into  many 
folds.  It  may  be  the  seat  of  some  local  peritonitis. 
Such  morbid  conditions  are  common.  Among  the  less 
frequent  changes  may  be  noted  the  following.  The 
sheath  may  be  greatly  thickened.  1:  In  a  case  re- 
ported by  Hauf,  the  thickness  of  the  three  layers  of  a 
chronic  intussusception  amounted  to  one  inch.§  This 
layer  not  infrequently  presents  ulcerations  of  its 
mucous  membrane,  which  are  often  multiple  and  may 
lead  to  perforation,  or  a  part  of  the  wall  of  the  sheath 
may  become  gangrenous.  This  local  gangrene  is 
often  due  to  the  pressure  of  a  greatly  curved  intussus- 
ceptum,  and  after  it  has  occurred  that  part  may  pro- 
trude through  the  hole  formed  in  the  sheath.  An 
excellent  example  of  such  protrusion  is  shown  in  Fig. 
41.  li     {See  also  Fig.  39.) 

In  a  case  of  acute  intussusception  of  the  ileum 
reported  by  Mr.  Morris,  there  was  extensive  gangrene 
of  the  sheath  on  the  sixth  day  with  a  threatening 
perforation  in  three  or  four  places.  ^  An  instance  of 
chronic  intussusception  had  been  placed  on  record 
where  the  sheath  was  entirely  ruptured  and  divided 
into  two  distinct  parts,  one  of  which  contained  the 
intussusceptum  while  the  otlier  was  empty. ^"^ 

*  Grissolle  ;  Bull,  de  la  Soc.  Anat.,  1835,  page  71. 
t  Holmes  ;  Path.  Soc.  Tran.s.,  vol.  viii.,  page  77. 
T  London  Hosp.  Musenm,  No.  Ae  45. 
§  Heidelb.  Med.  Annal,  1842,  b.  8,  s.  428. 
II  Univ.  Coll.  Museum,  No.  1,175. 
IfPath.  Soc.  Trans.,  vol.  xxviii.,  page  131. 
**  Journ.  de  Med.  de  SediUot. ,  toiiae  50,  1814,  page  446, 
N— 12 


194 


Intestinal  Obstruction.      [Chap. a^iii. 


Perforations    which     may     occur    either    in    the 
sheath  or  in  the  gut  above  the  intussusception,  are  a 


Fig.  41.— lutussusceptiou  of  the  Ileum.    Protrusion  of  the  Ictussus- 

ceptum  tlirough  an  ulcerated  Opening  in  the  Sheath. 
a,  upi>or  end  of  inv(jlvi'd  trut ;  b,  lower  end  of  involved  gut ;  c,  tlie  i>rotriulinp  in- 

tussusceptinu. 

little  more  frequent  in  chronic  than  in  acute   cases. 
Out  of  fifty-five  examples  of  chronic  intussusception 


Chap.  VIII.]   Intussusception:  Pathology.  195 

collected  by  M.  Rafinesque,"^  there  were  twelve  in- 
stances of  perforation.  Among  175  cases,  both  acute 
and  chronic,  Leichtenstern  found  twenty-eight  exam- 
ples of  perforation.  This  complication  is  most  common 
in  the  ileo-csecal  forms  and  least  common  in  the  ileo- 
colic. 

6.  Changes  in  tlie  intiissiisceptuiii. — The 
cylinders  involved  become  engorged  with  blood,  and 
haemorrhages  may  occur  in  their  substance  or  from 
their  surfaces.  It  is  from  the  latter  source  that  is 
derived  the  bleeding  that  is  so  often  a  conspicuous 
feature  in  intussusceptions,  especially  those  of  an 
acute  character.  The  walls  may  become  rapidly 
oedematous  and  greatly  swollen,  and  the  condition  run 
on  readily  to  gangrene.  In  more  chronic  cases  great 
thickening  of  the  layers  of  the  intussusceptum  may 
be  met  with  as  a  result  of  long-continued  congestion 
and  insidious  inflammation  of  a  low  type.  In  both 
acute  and  chronic  cases  the  thickening  of  the  layers 
may  be  equally  distributed  throughout  the  involved 
cylinders,  but  far  more  usually  it  is  most  conspicuously 
marked  in  two  places,  viz.  at  the  apex  of  the  intus- 
susceptum (.<?ee  Fig.  38),  and  along  its  convexity.  (/S'ee 
Fig.  37.)  Swelling  can  most  conveniently  occur  in 
these  places,  since  these  parts  of  the  intussusceptum 
are  the  most  free  from  pressure.  Along  the  concavity 
of  a  much  curved  tumour  much  cedema  would  be 
impossible,  the  layers  there  being  thrown  into 
tightly  compressed  folds  and  greatly  pressed  upon.  It 
must  also  be  noted  that  the  convexity  of  the  involved 
bowel  is  the  part  most  remote  from  the  entrance  of 
the  intestinal  vessels,  and  is  thus  the  more  likely  to 
first  show  e\ddences  of  vascular  disturbance.  For 
identical  reasons,  early  engorgement  may  be  expected 
at  the  apex  of  the  mass  when  constriction  at  the  neck 
is  prominently  marked.  The  swelling  and  thickenin,.; 
*  Th^se,  Paris,  1878. 


196  Intestinal  Obstruction.      [Chap. viii. 

about  the  apex  lead  to  the  knob-like  tumour  that 
offers  so  great  an  oljstacle  to  reduction.  It  is  also  the 
soft  swelling  at  the  extreme  end  of  the  intussusceptum 
that  gives  to  that  part  the  appearance  and  the 
response  to  the  touch  of  the  os  uteri  with  which  it 
has  been  so  many  times  compared.  In  both  acute 
and  in  chronic  cases  the  middle  cylinder  suffers  more 
and  shows  more  advanced  changes  than  does  the 
inner  cylinder.  Thus,  when  there  is  much  thickeniiig 
of  the  intussusceptum,  it,  as  a  rule,  mostly  concerns 
the  middle  layer.  The  thickness  of  this  layer  may  be 
considerable.  In  one  case,  recorded  by  Mr.  Sidney 
Jones,  the  width  of  the  wall  of  the  middle  cylinder 
varied  from  one-third  to  one  half  of  an  inch,"^  The 
intussusceptum  had  existed  for  nine  weeks.  The  inner 
cylinder  or  entering  layer  is  often  gi-eatly  contracted, 
a  circumstance  that  may  be  met  with  in  both  acute 
and  chronic  cases.  Thus  in  one  acute  case  this 
cylinder  was  found  to  be  no  larger  than  the  iliac 
artery.  Tlie  invagination  involved  the  ileum  and 
occurred  in  a  patient  thirteen  years  of  age.  f 

One  of  the  most  important  and  most  constant 
changes  in  the  intussusceptum  is  gangrene.  This 
condition  is  met  with  in  both  acute  and  chronic  cases, 
although  it  is  always  more  common,  and  usually  more 
extensive  in  the  former.  It  may  involve  the  whole 
mass  of  the  intussusceptum,  which  may  separate  at 
the  neck  and  be  discharged  from  the  bowel.  This 
occurs,  as  a  rule,  in  acute  invaginations,  although  it 
is  sometimes  met  with  in  clironic  cases  that  end 
acutely.  The  gangrenous  part  that  is  eliminated  may 
vary  in  length  from  a  few  inches  to  several  feet. 
Cruveilhier  has  recorded  an  instance  where  three 
metres  of  bowel  were  discharged  by  this  process. 
The  gangrene  usually  appears  first  and  remains  most 

*Path.  Soc.  Trans.,  vol.  viii.,  page  179, 
f  Ibid.,  vol.  xxviii.,  page  131. 


Chap.  VIII.]  Intussusception :  Pathology.  197 

advanced  in  the  middle  layer.  Thus  it  happens  that 
when  the  separation  of  the  intussusceptum  occurs 
the  middle  cylinder  may  be  disintegrated  and  in 
some  parts  missing,  while  the  entering  layer,  although 
dead,  may  still  be  sufficiently  well  preserved  to  show 
the  structure  of  the  bowel.  Sometimes  the  anatomi- 
cal details  of  the  part  are  singularly  well  preserved 
in  the  separated  intestine.  An  example  of  this  is 
afforded  by  a  specimen  in  Guy's  Hospital  *  showing 
the  caecum  and  the  whole  of  the  ascending  colon, 
which  were  passed  on  the  eleventh  day,  the  patient  re- 
covering. Sometimes,  however,  the  inner  cylinder  is 
more  extensively  involved  in  the  gangrenous  process 
than  is  the  middle  layer.  This  condition  is  usually 
met  with  in  ileo-csecal  invaginations,  where  the  part 
of  the  intussusceptum  formed  by  the  small  intestine 
may  perish  before  that  segment  formed  by  the  large. 
The  matter  of  an  interval  of  time  between  the  separa- 
tion of  the  inner  and  middle  layers  may  affect  the 
condition  of  the  gut  as  it  appears  when  discharged 
from  the  anus.  This  can,  however,  only  concern  in- 
tussuscepta  that  are  free  from  adhesions.  Suppose 
that  in  the  invagination  (Fig.  42,  a)  separation  takes 
place  along  the  transverse  line  6,  and  that  the  two 
cylinders  are  adherent,  it  is  obviously  a  matter  of 
indifference,  as  regards  the  appearance  of  the  dis- 
charged mass,  which  layer  separates  first.  The 
cylinder  that  first  comes  away  will  have  to  wait,  as  it 
were,  for  its  fellow,  and  they  will  then  be  discharged 
together,  retaining  the  mutual  relations  that  existed 
between  them  before  gangrene  set  in.  Suppose,  how- 
ever, that  no  adhesions  exist,  and  that  the  middle 
cylinder  separates  first,  as  is  most  usual  (Fig,  42,  5), 
the  separated  layer  may  immediately  unfold  itself, 
and  when  the  inner  cylinder  is  set  free  the  dead  gut 
will  be  discharged  as   one  continuous  tube,  with   its 

*  No.  1,875. 


198 


IntES  TINA  L    ObS  TR  UC  TION. 


[Chap.  VIII. 


a 


u 


^ 


u 


serous    covering   external   and    its   lumen   lined   by 

mucous  membrane. 

If,  however,  the  inner  layer  is  set  free  before  its 

fellow  (Fig.  42,  c),  it  may  become  unfolded,  and  when 

the  separation  is 
complete  the  gan- 
grenous bowel  will 
be  passed  as  a  con- 
tinuous tube,  but 
with  its  mucous 
layer  external  and 
with  its  lumen  lined 
with  the  serous  coat. 
In  such  cases  (and 
many  examples  h  a  ve 
been  reported)  the 
gut  is  said  to  have 
been  passed ' '  turned 
insideout."  Autliors 
who  describe  these 
cases  are  apparently 
under  the  impres- 
sion that  the  process 
of  "  turning  inside 
out"  is  effected   in 


y 


I. 


A 


m 


u 


A 


U?  y 


the  dead  gut   as  it 


_  passes  along  the  in- 

g  Fig.  42.  ^  testine.     This,  how- 

ever, is  not  only 
difficult  to  understand,  bub  is  suj^ported,  so  far  as  I  can 
ascertain,  by  no  evidence  of  any  kind.  I  have  already 
said  that  cases  marked  by  more  advanced  gangrene  of 
the  entering  layer  belong  to  the  ileo-csecal  type  of  in- 
vagination, and  it  is  only  among  examples  of  this  type 
that  I  have  been  able  to  find  instances  of  gangrenous 
intestine  passed  with  its  walls  turned  inside  out."^ 

*  A  good  example  of  this  apparently  inverted  bowel  is  given 


Chap.  VIII.]   Intussusception :  Pathology.  199 

In  some  instances  one  of  the  cylinders  alone  may 
be  separated  as  a  definite  tube,  the  other  coming  away 
in  the  form  of  gangrenous  shreds. 

In  another  set  of  cases,  which  as  a  rule  belong  to 
the  chronic  form  of  the  malady,  the  gangrene  com- 
mences at  the  apex  of  the  intussusceptum.  It  may 
remain  limited  to  this  part,  producing  but  limited  de- 
struction. This  is  illustrated  by  a  case  recorded  by 
Rafinesque  where  the  ileo-csecal  valve  that  formed  the 
point  of  the  intussusceptum  was  the  only  part  de- 
stroyed. More  usually,  however,  it  spreads,  and  the 
invaginated  mass  perishes  slowly,  and  is  eliminated  in 
shreds  and  putrid  fragments  which  may  pass  unrecog- 
nisefd.  In  one  case  of  chronic  invagination  where 
the  parts  were  becoming  gangrenous,  the  inner  and 
middle  layers  presented  a  rent  which  permitted  the 
intestinal  contents  to  pass  between  the  intussusceptum 
and  the  intussuscipiens."^ 

In  the  least  marked  form  of  the  destructive  pro- 
cess the  mucous  membrane  is  alone  involved.  This 
membrane  may  be  gangrenous  in  part  or  be  ulcerated, 
the  morbid  changes  in  any  case  being  as  a  rule  limited 
to,  or  most  marked  at,  the  apex.  Such  mi]d  forms  are 
much  more  common  in  chronic  than  in  acute  cases. 

Speaking  generally,  then,  it  may  be  said  that  in 
acute  invaginations  gangrene  is  more  common  and  ex- 
tensive, that  it  involves  principally  the  neck  of  the 
mass,  and  is  associated  with  an  elimination  of  the 
cylinders  more  or  less  in  their  entirety.  In  the 
chronic  forms  the  gangrene  is  less  rapid,  is  most 
marked  at  the  apex,  and  leads  usually  to  a  slowly 
progressing  destruction  wdiereby  the  intussusceptum 
is  eliminated  in  fragments. 

by  Dr.  Fagge  in  his  monograph  in  the  CtHy's  Hospital  Eeports. 
Dr.  Fagge  thinks  that  the  i>rocess  of  ' '  turning  inside  out "  goes  on 
duiing  the  expulsion  of  the  gangrenoiis  and  inert  mass. 

*  Lhonneur  and  Vulpian.  Bull,  de  la  Soc.  Anat.,  1855, 
page  100. 


200  Intestinal  Obstruction.      [Chap.viii. 

Among  less  common  and  less  important  changes 
in  the  intussnsceptiim  the  following  may  be  mentioned. 
Tiie  inner  and  middle  layers  may  alter  their  mutual 
positions  after  the  invagination  has  formed.  This,  I 
think,  is  demonstrated  by  those  cases  where  a  polyp 
is  associated  with  the  intussuscejition,  but  where  it  is 
found  some  way  up  upon  the  returning  layer  instead 
of  at  the  apex  of  the  tumour. 

The  mucous  membrane  may  be  densely  pigmented  in 
some  chronic  cases  as  a  result  of  long  abiding  congestion."^ 

Eafinesque  has  collected  one  or  two  cases  of 
chronic  intussusception  where  soft  and  scanty  ad- 
hesions existed  between  the  mucous  surfaces  of  the 
sheath  and  of  the  returning  layer. 

Lastly  may  be  noticed  the  remarkable  association 
of  ejntJielioiyia  with  chronic  intussusception.  In 
several  recorded  cases,  and  in  some  museum  specimens, 
I  find  that  an  epithelioinatous  growth  has  been  found 
upon  the  apex  of  the  intussusceptum.  Whether  this 
growth  preceded  or  followed  the  invagination  is  of 
little  moment.  It  is  very  certain,  however,  that  the 
neoplasm  may  grow  after  the  intussusception  has 
formed.  The  remarkable  and,  I  think,  unique  speci- 
men from  which  Fig  43  f  has  been  taken  shows  the 
internal  layer  of  an  ileo-csecal  invagination  enormously 
thickened  by  a  peculiar  dejDosit.  This  deposit  on  ex- 
amination proved  to  be  composed  of  the  tissue  of  a 
cylindrical  epithelioma.  The  specimen  was  obtained 
from  the  body  of  a  man,  aged  56,  avIio  had  presented 
symptoms  of  chronic  intussusception  for  about  twelve 
months  before  his  death.  He  was  under  the  care  of 
Mr.  Christopher  Heath,  who  relieved  the  patient  for  a 
little  while  by  establishing  an   artificial  anus.  |     The 

*  As  an  example,  see  Lctncct,  vol.  v.,  1803,  page  409. 
t  Univei-sity  College  Museum,  No.  ."),592. 

J  An  account  of  the  case  will  be  foiuiil  in  the  Registrar's 
Reports  of  University  Coll.  Hosp.  for  1881,  page  27,  case  No.  84. 


Chap.  VIII.]    Intussusception  :  Fa  thologv. 


2CT 


growth 


lumen  of  invagi- 
natecl  ileum  is 
greatly  reduced  in 
size.  The  neoplasm 
has  invaded  mainly 
the  convex  surface 
of  the  intussus- 
ceptum,  involving, 
however,  both  sur- 
faces at  the  apex  of 
the  protrusion. 

The 

along  the  convexity 
of  the  intussuscep- 
tum  has  been  evi- 
dently influenced  by 
the  lesser  degree  of 
pressure  exercised 
upon  that  part  of 
the  mass.  It  is  not 
improbaljle  that  in 
this  case  the  cylin- 
droma commenced 
at  the  ileo-csecal 
valve,  and,  acting 
as  a  foreign  sub- 
stance, produced  the 
invagination,  and 
then  continued  to 
develop  in  the  di- 
rection offering  the 
least  resistance. 


Fig.  43.  -Clu'onic  Intus- 
susception with  Epi- 
tlPiliomaof  tlie  middle 
Layer. 

A  1iouf,'i"e  occupios  the  lumen 
of  the  iiite.stine. 


202  Intestinal  Obstruction.       ichap  ix. 

There  lias  recently  been  added  to  the  Museum  of 
the  lioyal  College  of  Surgeons  a  specimen  which  very 
closely  resembles  the  one  just  descriljed.*  It  shows 
an  intussusception,  the  middle  layer  of  which  has 
undergone  an  extreme  degree  of  thickening.  This 
thickening  involves  the  a]3ex  of  the  intussuscej)tum 
and,  to  a  much  greater  extent,  the  convexity  of  it. 
On  section  the  mass  has  an  appearance  almost 
identical  with  that  presented  by  Mr.  Heath's 
specimen,  and  indeed  the  resemblance  between  these 
two  specimens  is  singularly  striking.  Comparing  it 
with  Mr.  Heath's  case  one  would  not  have  hesitated 
to  declare  it  also  an  example  of  epithelioma,  but  Dr. 
Goodhart,  by  whom  the  specimen  was  j)i'esented  to 
the  College,  assures  me  that  a  microscopic  examina- 
tion of  the  thickened  gut  wall  revealed  merely  the 
results  of  chronic  inflammation. 

Another  specimen  in  the  College  of  Surgeons 
Museum  f  shows  an  cpitheliomous  growtli  attacking 
the  apex  of  an  intussusception  of  the  rectum.  The 
patient  from  whom  the  specimen  was  obtained  had 
presented  symptoms  for  nine  months. 


CHAPTER    IX. 

THE    ETIOLOGY    OF    INTUSSUSCEPTION. 

1.  X'lie  iiiitiBcdiatc  cause. — Many  theories 
have  been  advanced  to  explain  the  invagination  of 
one  portion  of  the  intestine  into  another.  Some  of 
these  have  not  withstood  the  test  of  time^  while 
others  are  too  vague  and  too  indefinitely  expressed 
to  be  susceptible  of   criticism.     With   such   theories 

*No.  2,G99a.  t  No.  1,380. 


Chap.  IX,]      Intussusception:  Causes.  203 

and  with  the  verbose  discussions  to  which  they  have 
given  rise  I  propose  to  have  no  concern ;  but  will 
consider  merely  the  one  explanation  that,  I  venture 
to  think,  has  in  it  the  greatest  element  of  truth. 

There  is  practically  unanswerable  evidence  to 
show  that  intussusception  is  brought  about  by 
irregular  action  in  the  muscular  wall  of  the  intestine. 

The  precise  nature  of  that  irregularity  may  be 
a  matter  open  to  some  question.  So  far  as  the  facts 
at  present  at  our  disposal  would  show,  it  would 
appear  that  an  intussusception  occurs  either  at  a 
point  where  the  gut  is  the  seat  of  a  limited  and 
severe  muscular  contraction,  or  at  a  point  where  a 
paralysed  segment  joins  a  part  still  capable  of 
vioforous  contraction.  Thus  had  arisen  the  division 
of  intussusceptions  into  two  forms,  the  invaginatio 
spasmodica  and  the  invaginatio  paralytica. 

The  chief  data  in  connection  with  this  subject  have 
been  furnished  by  the  elaborate  vivisection  experiments 
of  Nothnagel,"^  of  which  some  account  may  now  Ije 
given.  The  intestines  of  a  rabbit  having  been 
exposed  with  suitaVjle  precautions,  a  segment  of  the 
bowel  is  stimulated  by  means  of  a  faradaic  current 
applied  through  electrodes  placed  so  close  together 
that  a  perfectly  circumscribed  ring-like  contraction 
is  produced.  On  increasing  the  current  a  contraction 
follows  which  extends  for  a  consideraVjle  distance 
upwards,  i.e.  towards  the  stomach,  but  only  for  a 
very  slight  extent  downwards.  The  gut  at  the  point 
of  stimulation  is  by  this  time  converted  into  a 
perfectly  pale  hard  cord  from  contraction  of  the 
circular  muscle.  Proceeding  upwards,  the  contracted 
segment  is  found  to  pass  either  gradually  into  the 
normal  intestine  or  to  end  quite  abruptly.  In  the 
latter  instance  a  minute  intussusception  forms.     The 

*B6itrage  zur  Physiologie  and  Pathologie  des  Dai-mes,  pa^e  12. 
Berlin,  1884. 


204 


InTES  TINA  L    ObS  TR  UC  TION. 


[Chap.  IX. 


wide  tube  of  the  normal  gut  above  slides  a  little 
over  the  contracted  part  below.  Thus  is  formed  a 
retrograde  intussusception.  Such  invaginations,  how- 
ever, are  always  very  small,  show  no  tendency  to 
increase  and  are  indeed  of  only  momentary  duration. 
Proceeding  downwards  from  the  point  of  stimulation 
a  very  different  condition  is  met  with.  A  proper 
descending  invagination  is  found  to  be  forming.  On 
closely  examining  its  mode  of  development,  these 
points  are  to  be  noticed.  The  spot  at  which  the 
^  electrodes  are  applied  forms  practically 

a  fixed  point.      The  normal  gut  immedi- 
f^  ately  below  the   contracted  part  turns 

itself  upwards  to  a  slight   extent  over 
this    strongly    contracted    and    greatly 

\.  narrowed  portion.     A  minute  invagina- 

tion is  thus  i)roduced,  which  increases 
solely  at  the  expense  of  the  intussus- 
cipiens.  This  mode  of  development  is 
clearly  demonstrated  by  the  following 
experiment.  In  Fig.  44  the  condition 
of  the  gut  at  the  time  of  the  experiment 
is  shown,  c  is  the  upper  end  {i.e.  to- 
wards the  stomach),  d  is  the  lower  end, 
and  e  is  the  contracted  segment.  At 
one  spot  a  on  the  bowel  a  fine  blue 
thread  was  drawn  through  the  serous 
coat  and  then  cut  short.  At  another 
point  h  lower  down  a  red  thread  was 
in  like  manner  introduced.  The  elec- 
trodes were  applied  at  the  point  a,  rej^re- 
sented  by  the  blue  thread.  An  ascend- 
ing contraction  e  of  the  bowel  followed, 
while  below  the  point  of  stimulation  an 
invagination  formed.  During  the  development  of 
this  intussusception  the  electrodes  remained  unmoved 
at    a,     and    the    blue     thread    kept    always    at     the 


Chap.  IX.]        Intussusception:  Causes.  205 

upper  retiring  angle  or  neck  of  the  invagination. 
Tiie  red  thread,  however,  moved  gi-adually  upwards 
until  it  reached  the  upper  retiring  angle,  when  it 
disappeared.  After  a  while,  Avhen  the  intussuscep- 
tion was  cut  open,  the  red  thread  was  found  about 
the  middle  of  the  middle  layer. 

The  invaginations  so  produced  existed  for  a  certain 
length  of  time,  and  then  disappeared  as  the  gut 
became  restored  to  its  normal  condition. 

Nothnagel  found  that  stimulation  of  the  bowel 
above  the  intussusception  had  no  effect  in  promoting 
its  unfolding,  while  stimulation  of  the  intussus- 
cipiens  merely  caused  the  invagination  to  become 
all  the  more  rigid.  Stimulation,  however,  of  the  gut 
below  the  involution  caused  an  ascendino-  contraction, 
by  means  of  which  the  intussusception  was  at  once 
relieved. 

Thus,  in  one  case  where  an  invagination  of  the 
colon  had  been  artificially  produced,  it  was  made  to 
disappear  by  an  antiperistalsis  induced  by  an  enema 
of  a  solution  of  common  salt. 

The  experiments  described  so  far  refer  to  invagi- 
natio  spasmodica.  Nothnagel's  investigation  of  the 
invaginatio  j^av^^lytica  give  the  following  results. 

A  segment  of  bowel  from  three  to  six  inches 
in  length  was  entirely  paralvsed  by  crushing.  When 
stimulation  was  applied  above  the  paralysed  part 
nothing  followed  save  the  usual  ascending  contraction. 
When,  however,  the  electrodes  were  applied  to  the 
gut  immediately  below  the  inert  segment  a  typical 
descending  intussusception  developed.  This  invagina- 
tion gTew  solely  at  the  expense  of  the  normal  bowel. 
The  paralysed  part  was  not  concerned  in  it,  the 
electrodes  remaining  quite  unmoved  at  the  original 
place  of  application,  just  as  occurred  in  the  previous 
experiment  at  the  mark  of  the  blue  thread. 

These  researches  serve  to  demonstrate,  so  far  as 


2o6  Intestinal  Obstruction.         [Chap.  ix. 

they  go,  the  existence  of  both  a  spasmodic  and  a 
paralytic  form  of  intussuscei)tion.  Nothnagel  con- 
siders that  the  former  variety  is  infinitely  more 
common  than  the  latter,  and  the  evidence  afforded 
by  clinical  observation  would  support  his  opinion. 

The  distinction  between  these  two  forms  is  not 
of  material  imj^ortance.  The  simple  fact  remains 
that  intussusception  depends  upon  irregular  action  in 
the  muscular  wall  of  the  intestine. 

The  experiments  detailed  should  serve  to  correct 
the  common  impressions  that  exist  as  to  the  produc- 
tion of  invagination,  and  that  are  expounded  in  the 
chief  text-books.  There  is  no  driving  of  a  contracted 
segment  of  gut  into  the  non-contracted  part  below 
by  the  "  propulsive  action  of  the  intestine."  Peris- 
talsis in  the  bowel  above  the  contracted  portion 
appears  to  have  no  influence  in  the  formation  of  the 
intussusception ;  and  it  is  a  question  rather  of  one 
piece  of  gut  being  drawn  over  another  than  of  one 
part  being  thrust  into  the  subjacent  segment.  It 
is  important  also  to  note  that  the  whole  length  of  the 
contracted  segment  is  not  used  in  the  invagination 
as  is,  I  believe,  very  usually  supposed. 

I  do  not  think  that  sufiicient  importance  has 
been  attached  to  the  action  of  the  longitudinal  layer 
of  muscle  in  producing  intussusception,  although 
Nothnagel  makes  some  mention  of  the  probable  part 
it  plays. 

If  the  arrangement  of  parts  be  considered  in  that 
area  of  the  bowel  where  a  vigorously  contracted  seg- 
ment joins  a  non-contracted  portion,  the  condition  of 
the  muscle  of  the  intestine  will  be  as  follows  :  The 
action  of  the  circular  layer  must  cease  abruptly  at  the 
line  where  the  contracted  and  non-contracted  parts 
meet,  since  the  fibres  of  this  layer  are  placed  at  right 
angles  to  the  long  axis  of  the  gut.  The  action  of  the 
longitudinal  fibres  must  extend,  however,  beyond  the 


Chap.  IX. j        Intussusception:  Causes.  207 

line  of  meeting.  If  they  be  considered  to  act  from 
the  contracted  segment  as  from  a  fixed  point,  it  is 
evident  that  they  will  tend  to  draw  the  wide  non- 
contracted  segment  over  the  narrow  and  contracted 
piece.  In  this  way,  by  the  drawing  of  one  part  of 
the  intestinal  tube  over  another  part,  the  intussuscep- 
tion is  formed,  and  this  mode  of  formation  ai)plies  as 
well  to  the  retrograde  as  to  the  descending  invagina- 
tions. 

When  once  the  invagination  has  taken  place  it  is 
probable  that  the  intussusceptum  acts  the  part  of  a 
foreign  body  in  the  intestine,  stimulates  the  intus- 
suscipiens  to  contract  and  so  force  along  the  inturned 
cylinder. 

Many  clinical  facts  support  the  association  of 
intussusception  with  disordered  intestinal  movements. 
Conspicuous  are  the  attacks  of  colic,  which  are  so 
early  and  so  marked  a  sign  of  the  condition ;  the 
frequent  association  of  the  intussusception  with  states 
attended,  or  apt  to  be  attended,  by  disturbed  peri- 
staltic movements,  such  as  diarrhoea,  intestinal  polypi, 
the  presence  of  masses  of  undigested  food  in  the  bowel, 
and  the  like."^ 

Intussusceptions  have  been  met  with  in  cases 
where  a  cause  of  grave  intestinal  disturbance  already 
existed.  Thus  Mr.  Joseph  Bell  reports  a  case  of 
strangulation  by  band,  for  the  relief  of  which  he 
performed  laparotomy.  On  opening  the  abdomen  he 
discovered  an  invagination  of  the  bowel,  four  inches 
in  length,  which  was  readily  reduced.!  The  occur- 
rence of  intussusception  after  injury  to  the  abdomen 
may  depend  upon  some  local  disturbance  in  the 
activity  of  the  intestine  resulting  from  the  lesion.  In 
some   few   instances   intussusceptions   have   occurred 

*Griesenger  has  sliowu  that  in  dysentery  a  paralysis  of  i\ 
section  of  the  intestine  is  not  uncommon. 
■\  Edinh.  Med.  Journ.,  1882,  page  53, 


2o8  Intestinal  Obstruction.         ichap.  ix. 

after  typhoid  fever,  after  cholera,  after  severe  rauco- 
enteritis,  and  after  the  reduction  of  strangulated 
hernia,  all  being  conditions  under  which  disordered 
intestinal  action  may  be  expected. 

It  may  be  noted  also  that  invaginations  are  most 
common  in  the  young,  in  Avhom  nerve  processes  are 
active,  and  in  whom  the  tissues  are  susceptible  of 
ready  change  and  capable  of  being  readily  disturbed. 

The  "  invaginations  of  the  dying,"  moreover,  are 
most  apt  to  occur  in  those  who  have  died  of  some 
grave  nerve  lesion,  such  as  meningitis,  and  in  whom 
it  may  not  be  unreasonable  to  expect  a  disturbance  of 
so  important  a  part  of  the  nervous  system  as  that 
supplying  the  intestines. 

And  here,  by-the-by,  I  might  venture  to  suggest 
that  slio'ht  invaijinations  havinsc  a  more  or  less  mo- 
mentary  existence  are  probably  much  more  common 
in  the  human  subject  than  is  supposed.  It  seems  to 
me  that  there  is  good  reason  for  believing  that  some 
attacks  of  colic,  especially  such  as  follow  upon  the 
ingestion  of  unassimilable  food,  may  have  for  their 
anatomical  basis  a  series  of  temporary  invaginations 
of  the  bowel. 

The  resemblance  between  these  colicky  attacks  and 
an  attack  of  intussuscci^tion  appears  to  be  often  pecu- 
liarly complete,  and  the  divergence  between  the  two 
sets  of  cases  to  depend  simply  upon  the  element  of  du- 
ration or  persistence.  In  Ijoth  there  is  the  same  kind 
of  pain,  the  same  disposition  to  vomit,  the  same  form 
of  constitutional  depression,  and  often  the  common 
symptom  of  marked  tenesmus.  When  the  invagina- 
tion becomes  strangulated  the  resemblance  of  course 
ceases.  It  is  dilhcult  to  avoid  the  belief  that  many, 
perhaps  most,  of  the  cases  of  protracted  "  spasms " 
met  with  in  delicate  women,  and  in  persons  liable  to 
digestive  disturbances,  are  due  to  definite  intussuscep- 
tions, which   in   time   reduce  themselves   instead    of 


Chip.  IX.]        Intussusception:  Causes.  209 

passing  on  to  strangulation.  The  sudden  onset  of 
these  attacks,  their  equally  sudden  cessation,  and  the 
manner  in  which  they  yield  to  opiates,  appear  to 
strongly  support  this  belief. 

The  peculiarly  frequent  occurrence  of  invagina- 
tions in  the  ileo-cascal  region  requires  some  slight 
explanation.  This  frequency  may  dej)end  to  some 
extent  upon  the  difference  in  size  between  the  ileum 
and  the  colon,  and  the  ease  with  which  the  former 
could  be  prolapsed  into  the  capacious  crecum.  Facili- 
ties for  inTagiuation,  moreover,  are  offered  by  the  fixed 
position  of  the  c?ecum  as  compared  with  the  mobility 
of  the  lower  ileum,  and  by  the  circumstance  that  at 
the  valve  of  Bauhin  an  active  segment  of  the  bowel 
meets  a  comjiaratively  inert  portion. 

Leichtenstern  and  others,  however,  have  pointed 
out  the  great  influence  that  the  sphincter-like  valve 
may  have  in  producing  invaginations  when  their 
formation  is  associated  with  tenesmus.  They  have  com- 
pared the  ileo-ciecal  orifice  to  the  anus,  and  the  intus- 
susceptions of  this  region  to  prolapse  of  the  rectum. 
The  matter  cannot  be  better  expressed  than  in 
Leichtenstern's  own  words.  '■'  If  we  consider  that  the 
ileo-C£ecal  opening  is  distinguished  by  a  sphincter,  the 
contraction  of  which  can  increase  to  powerful  tenes- 
mus, we  recognise  that  there  is  a  complete  analogy 
between  the  conditions  of  invagination  in  the  reoion 
of  the  caecum  and  the  difterent  kinds  of  prolapse  of  the 
rectum,  which,  like  ileo-c£ecal  invaginations,  is  found 
most  frequently  in  early  childhood.  Just  as  anal 
tenesmus,  excited  by  any  cause  whatever  (rectal 
blennorrhoea,  profuse  diarrhoea),  usually  excites  and 
accompanies  prolapse  of  the  rectum,  so  is  ileo-csecal 
tenesmus,  excited  by  catarrh  or  abnormal  irritability 
of  the  terminal  portion  of  the  ileum,  of  gTeat  im- 
portance in  the  production  of  many  ileo-csecal  and 
ileo-colic  invaginations.  In  many  cases  in  which  we 
0—12 


2IO  Intestinal  Obstruction,         [Chap.  ix. 

see  invaginations  in  the  region  of  the  c?ecum  follow 
prolonged  diarrhoea  or  colic,  the  taking  of  unsuital)le 
food,  or,  especially  in  early  infancy,  the  withdrawal  of 
the  mother's  milk  and  the  substitution  of  improper 
food,  csecal  tenesmus  plays  an  important  part.  If  the 
caecum  and  the  colon  are  rendered  easily  movable  by 
their  mesentery,  as  is  regularly  the  case  during  early 
life,  the  repeated  and  more  forcible  peristaltic  pres- 
sure towards  the  persistently  contracted  ileo-csecal 
sphincter  causes  ileo-caecal  invagination.  If  the  csecum 
be  firmly  fastened  down,  so  that  it  cannot  be  turned 
in  and  invaginated  into  the  colon,  prolapse  of  the 
ileum  into  the  colon  takes  place,  with  formation  of  an 
ileo-colic  invagination,  just  as  prolapse  of  the  rectum 
may  follow  violent  anal  tenesmus.  If  neither  of  these 
happens,  invagination  of  the  lowest  part  of  the  ileum 
may  occur,  as  is  the  case  also  in  the  rectum  when  it 
becomes  invaginated  in  itself  above  an  obstinately 
contracted  (tenesmus)  sphincter,  and  is  finally  pro- 
lapsed. If  ileo-C8ecal  invaginations  are  very  common 
in  children,  and  ileum  invaginations,  on  the  contrary, 
very  rare,  the  reason  lies  in  the  greater  mobility  of 
the  caecum  and  ascending  colon  allowed  by  their 
mesentery,  and  the  consequent  removal  of  an  obstacle 
to  invagination.  In  adults  this  element  is  not  re- 
moved, and  we  find  ileiuii  invaginations  as  frequent 
as  ileo-csecal."  "^ 

2.  The  remote  or  exciting:  cause. — A  great 
deal  has  been  written  upon  the  question  of  the  ex- 
citing causes  of  intussusception,  and  stress  laid  upon 
the  circumstance  that  with  a  more  perfect  knowledge 
of  these  causes  a  more  definite  form  of  prophylactic 
treatment  may  be  attempted.  Precise  knowledge 
upon  this  point  is  still,  however,  wanting.  From  an 
examination  of  a  number  of  reported  cases,  and  from 
certain  statistics  bearing  upon  the  matter  of  etiology,  it 
*  Loc.  cit .  Ziemsseu's  Cyclopaedia,  vol.  vii.,  page  617. 


Chap  IX.]        Intussusception:  Causes.  211 

is  probable  tliat  in  100  examples  of  intussusception 
the  exciting  causes  would  be  distributed  as  follows  : 

1.  No  evident  exciting  cause      ....       62  per  cent. 

2.  Diarrhoea,    dysentery,    enteritis,    marked  )  g 

irregvilarity  of  the  bowels         .        .       )  " 

3.  Polypi 5        ,, 

4.  Ingesta 5       „ 

5.  Injuries  and  exposure  to  cold       .         .         .  5        „ 

6.  Certain  acute  and  chronic  ailments  which 

may  or  may  not  have  had  a  concern 
in  the  etiology,  such  as  typhoid  fever, 
whooping  cough,  measles,  scarlet  fever, 
small-pox,  cholera,  and  hernia ;  with 
these  may  be  included  pregnancy  and 
labour 15       ,, 


Total     100 

Some  more  detailed  notice  may  be  taken  of  the 
circumstances  to  be  considered  under  these  six  head- 
ings. 

1.  It  would  appear  that  in  more  than  half  of  the 
cases  that  have  been  recorded  no  cause  could  be  found 
for  the  invagination.  It  is  probable  that  this  per- 
centage is  too  high,  since  in  many  of  the  cases  coming 
under  this  heading  the  evidence  is  negative,  the 
patient's  previous  condition  not  having  been  detailed. 
Leichtenstern,  however,  out  of  a  total  of  593  cases 
found  no  less  than  111  in  which  it  was  distinctly 
stated  that  the  trouble  appeared  abruptly  in  patients 
enjoying  at  the  time  perfect  health. 

In  reading  through  a  collection  of  well  recorded 
cases  one  cannot  but  be  struck  with  the  great  fre- 
quency with  which  invaginations  have  appeared  in 
persons  of  delicate  health.  Many  are  simply  de- 
scribed as  delicate,  others  as  wasted,  several  have 
been  anaemic,  and  not  a  few  have  been  tlie  subject 
of  heart  disease   or  of  chronic  pulmonary  mischief."^ 

*For  marked  examples  see  Path.  Soc.  Trans.,  vol.  xxiv.,  page 
108  (anaemia).  Ibid.,  vol.  xxxii.,  page  82  (heart  disease),  ami 
Bull,  de  la  Soc,  Anat.,  1867,  page  136  (chronic  phthisis). 


212  Intestinal  Obstruction.        [Chap.  ix. 

Although  the  matter  cannot  be  expressed  numerically, 
it  would  certainly  appear  that  intussusception  is  more 
common  in  the  delicate  than  in  those  possessing  vigo- 
rous health. 

2.  Probably  the  cases  coming  under  this  heading 
are  represented,  on  the  other  hand,  by  too  low  a  figure. 
The  association  of  intussusception  with  diarrhoea  is 
marked,  although  in  some  instances  I  think  the  purg- 
ing has  been  rather  a  symptom  of  the  disease  than  a 
cause  of  it.  Possibly  in  many  cases  of  chronic 
diarrhoea  in  children,  where  the  purging  suddenly 
ceases  some  little  while  before  death,  and  where  the 
mothers  are  apt  to  say  that  "  the  child  was  purged 
until  there  was  nothing  more  to  pass,"  there  may  be 
an  intussusception  present  to  account  for  the  altered 
circumstances  of  the  case. 

Intussusceptions  presumably  due  to  diarrhoea  are 
most  commonly  met  with  in  children,  and  are  most 
often  of  the  colic  or  ileo-c?ecal  varieties.*  In  one  or  two 
cases  an  intussusception  has  appeared  after  the  ad- 
ministration of  powerful  aperients. 

3.  An  example  of  the  association  of  an  intus- 
susception with  polyp  is  shown  in  Fig.  40.  f  The 
polyp  is  usually  found  attached  to  the  apex  of  the 
intussusceptum,  although  in  rare  cases  it  may  be 
found  about  its  middle,  owiug  probably  to  a  shifting 
of  the  entering  and  returning  layers.  In  some  ex- 
amples the  association  is  no  doubt  accidental,  as  was 
probably  the  case  in  a  specimen  descril3ed  by  Sir 
Prescott  Hewett,  where  a  pedunculated  polyp,  the  size 
of  a  pear,  was  attached  to  the  intussuscipiens  just 
below  the  invagination.  \     The  polypi  in  these  cases 

*For  marked  examples,  see  Lancet,  vol.  i.,  1876,  page  12. 
Path.  Soc.  Trans.,  vol.  viii.,  page  177.  St.  Bart.'s  Hosp.  Reports, 
1876,  page  95. 

t  See  also  specimens  in  Lond.  Hosp.  Museum,  No.  Ae  45,  and 
Coll.  of  Surgeons  Museum,  No.  1,380  a. 

^  Path.  Soc.  Trans.,  vol.  i.,  page  95. 


Chap.  IX.]        Intussusception:  Causes.  2 it, 

vary  in  size  from  a  hazel  nut  to  an  Qgg  or  a  pear. 
As  a  rule,  however,  they  are  quite  small.  They  are 
oval,  usually  pedunculated  and  nearly  always  attached 
to  the  convex  wall  of  the  intestine.  In  two-thirds  of 
the  cases  they  are  found  attached  to  the  lower  ileum, 
and  thus  they  most  frequently  lead  to  enteric,  or  to 
ileo-ceecal,  or  ileo-colic  invaginations.  They  have  pro- 
duced intussusceptions  inthe  jeyunum,  the  duodenum,"* 
the  colon  and  the  rectum.  They  more  usually  pro- 
duce acute  than  chronic  forms  of  the  malady.  As  a 
rule,  only  one  polyp  is  found  associated  with  the  in- 
vagination. Dr.  Fuller,  however,  records,  a  case  where 
thirty  of  such  tumours  were  found,  with  the  largest  of 
which  an  intussusception  was  involved.!  In  one  re- 
markable instance  three  polypi  at  some  distance  apart 
caused  three  separate  intussusceptions  in  the  same 
patient.  The  three  tumours  formed  were  visible 
during  life.  J 

4.  The  severe  colic  often  produced  during  the 
passage  of  undigested  food  through  the  intestine 
would  suggest  that  masses  of  such  matters  may  not 
infrequently  cause  invagination.  A  good  example  of 
this  association  is  shown  in  a  specimen  in  University 
College  Museum.  §  The  specimen  is  from  the  small 
intestine  of  an  animal,  and  it  will  be  seen  that  the  in- 
vagination has  formed  itself  about  a  large  piece  of  un- 
digested tendon.  In  a  case  recorded  by  M.  Le  Moyne,  it 
is  supposed  that  a  mass  of  partly  digested  beans  found 
at  the  autopsy  in  the  sigmoid  flexure  had,  during  its 
passage  through  the  intestine,  produced  no  less  than 
six  invaginations,  which  were  found  after  death.  ||  In 
a  patient  of  M.  Dubois',^  the  symptoms  appeared  soon 

*  Bull,  (le  la  Soc.  Anat.,  1864,  page  37. 
t  Path.  Soc.  Trans.,  vol.  xxi.,  page  188. 
i  Bull,  de  la  Soc.  Anat. ,  1870,  page  200. 

I  No.  1,170.     , 

II  Contrib.  a  I'Etude  des  Invaginations.     Paris,  1879.     These, 
ni  Gaz.  des  Hop.,  18G3,  page  298. 


214  Intestinal  Obstruction.         [Chap.  ix. 

after  swallowing  a  number  of  clierry  stones.  In  a 
case  by  Mr.  Gay,"^  a  mass  of  rice  was  found  in  the 
intussusceptum,  and  other  instances  of  this  association 
of  undigested  food  masses  with  invagination  have 
been  given  with  equal  clearness. 

5.  The  relation  between  injuries  and  invaginations 
is,  it  must  be  confessed,  not  very  clear.  The  intes- 
tinal trouble  has  appeared  after  blows  upon  the 
abdomen,  after  a  patient  has  been  ridden  over,  and 
after  severe  compression  of  the  belly.  Three  or  four 
examples  have  been  given  where  the  symptoms  of  in- 
vagination developed  suddenly  while  the  child  was 
being  "jumj)ed"  in  some  one's  arms.f  Leichtenstern 
has  collected  six  cases  where  the  symptoms  apjDeared 
after  exposure  to  cold.  In  a  solitary  instance  the 
evidences  of  invagination  came  on  shortly  after  drink- 
ing much  cold  water  while  sweating.  In  the  Lancet  for 
1867  is  recorded  the  case  of  a  child,  aged  five,  who  died 
in  four  days  from  the  effects  of  a  burn.  For  the  last 
forty-eight  hours  of  its  life  there  had  been  feculent 
vomiting.  The  autopsy  revealed  three  invaginations  ; 
two  v/ere  recent,  but  the  third  had  evidently  existed 
for  some  little  time.  % 

6.  Under  this  heading  it  is  impossible  to  assign 
any  definite  position  in  the  etiology  of  intussusception 
to  the  various  maladies  that  are  mentioned.  Not  in- 
frequently the  association  has  probably  been  purely 
casual. 

In  other  instances  the  debility  produced  by  the 
previous  ailment  has  probably  been  an  influential 
factor  in  the  causation  of  the  disorder  in  the  bowels. 
In  those  examples,  however,  where  invaginations  have 
followed  upon  cholera  and  hernia,  it  may  be  allowed 

*  Monograph,  loc.  cit. 

f  llilliet  et  Barthez  ;  Trait(^  clinique  et  prat,  des  Mai.  des  En 
fants,  1861,  tome  i.,  page  806  (two  cases).  Latwet,  vol.  i.,  1877, 
page  273. 

X  Dr.  Heckford;  Lancet,  voL  i.,  18G7,  page  362. 


Chap. X.]       Intussusception:  Symptoms.  215 

that  a  morbid  state  of  the  bowel  has  been  induced 
that  could  readily  lead  to  intussusception. 

Among  the  rarer  causes,  real  or  apparent,  of  in- 
vaginations, may  be  mentioned  stricture  of  the  ileo- 
cascal  A*alve,  growths  or  vegetations  attached  to  the 
valve,"^  and  cancerous  affections  of  the  intestine. f  One 
of  the  most  remarkable  cases  of  invagination  is  illus- 
trated by  a  specimen  in  Guy's  Hospital  Museum  that 
is  probably  unique.  It  shows  a  small  and  short 
Meckel's  diverticulum  springing  from  the  lower  ileum. 
This  diverticle  had  become  inverted  so  as  to  project 
into  the  lumen  of  the  intestine,  and  when  in  that 
position  had  led  to  the  formation  of  an  intussus- 
ception.! 


CHAPTER  X. 

THE    SYMPTOMS    OF    INTUSSUSCEPTION. 

Following  the  excellent  classification  of  Eafinesque, 
intussuscej)tion,  when  regarded  from  a  clinical  stand- 
point, may  be  divided  into  four  forms.  1.  The  ultra- 
acute,  when  the  patient  dies  within  the  first  twenty- 
four  hours.  2.  The  acute,  when  the  duration  of  the 
disease  extends  between  two  to  seven  days.  3.  The 
subacute,  when  it  extends  between  seven  and  thii-ty 
days.  4.  The  chronic,  when  the  malady  lasts  lieyond 
the  period  of  one  month.  No  definite  line,  of  course, 
can  be  dra^Ti  to  separate  these  various  forms  from 
one  another.  The  division  is  arbitrary,  but  from  a 
purely  clinical  point  of  view  the  arrangement  is  con- 
venient. 

*  Dance;  Ai'cli.  C4eu.  de  Med.,  1832,  xxviii.,  page  177. 
t  Sec  specimen  Xo.  1,380  in  Coll.  of  Siu-geons  5luseiim,  show- 
ing an  invagination  of  the  rectum  depending  upon  an  epithelioma. 
%  Guy's  Hosp.  Museum,  No.  1,819-'''. 


2  1 6  InTES  TINA  L    ObS  TR  UC  TION.  [Chap.  X. 

It  will  be  well  to  consider  in  the  first  place  some 
circumstances,  such  as  those  of  sex,  age,  etc.,  that  are 
common  to  all  forms  of  invagination  ;  and  then  to 
review  the  symptoms  as  thej  concern,  first  acute  and 
subacute  cases,  and  secondly  as  they  concern  the 
chronic  forms. 

The  chief  clinical  features  of  intussusception  Avill 
be  considered  when  dealing  with  cases  belonging  to 
the  former  category. 

FreqtBeBiey.— In  his  statistics  of  1,152  cases  of  in- 
testinal obstruction  of  all  kinds  (excluding  hernise  and 
affections  of  the  rectum),  Leichtenstern  places  412 
cases  of  intussusception.  Thus  invaginations  form 
about  30  per  cent,  or  a  little  less  than  one-third  of  all 
species  of  obstruction  of  the  bowels. 

From  an  examination  of  sundry  tables  of  mortality, 
and  from  my  own  collection  of  recorded  cases,  I  think 
that  among  100  examples  of  intussusception  the  chief 
clinical  varieties  may  be  divided  as  follows  :  acute, 
50  per  cent.,  subacute  32  per  cent.,  and  chronic  18 
per  cent. 

Sex. — Intussusception  is  more  common  in  males 
than  in  females.  Of  Leichtenstern's  442  cases,  285 
occurred  in  males  and  157  in  females.  Mr.  Gay, 
however,  dealing  with  1,289  cases  obtained  from  the 
Registrar  General's  Reports  for  five  years,  finds  the 
proportion  to  be  678  males  to  611  females,  or  about 
I'll  to  1.  The  age  of  the  patient,  however,  has  cer- 
tainly a  conspicuous  infiuence  upon  this  proportion. 
The  younger  the  individual  the  more  marked  is  the 
preponderance  of  the  male  sex.  Thus,  in  twenty-five 
cases  in  children,  collected  by  Rilliet,  twenty-two  were 
in  male  subjects  and  three  only  in  females.  Mr. 
Gay's  statistics,  however,  are  probably  more  reliable. 
He  shows  that  in  children  under  one  year  old  the 
pro|)ortion  of  males  to  females  is  as  163  to  93.  As 
age  advances  the  disproportion  becomes  gradually  less 


Chap.  X.]       Intl'ssusception:  Svmptoms.  217 

marked,  until  between  tlie  ages  of  twenty-five  and 
thirty-five  the  number  of  cases  met  with  in  the  two 
sexes  is  about  equal.  After  thirty-five  there  appears 
to  be  a  preponderance  on  the  side  of  the  females,  the 
proportion  between  the  ages  of  thirty-five  and  forty- 
five  being,  according  to  Mr.  Gay,  as  74  females  to  55 
males. 

This  matter  appears  to  be  somewhat  influenced 
also  by  the  chronicity  of  the  case.  Thus,  out  of 
fifty-one  cases  of  chronic  invagination  collected  by 
Eatinesque,  thii'ty-eight  were  males  and  thirteen 
females. 

Ag"e. — Intussusception  occurs  so  frequently  in 
children  that  it  forms  the  most  common  variety  of 
obstruction  to  which  they  are  liable.  More  than  50 
per  cent,  of  the  cases  are  met  with  during  the  first 
ten  years  of  life,  and  about  25  per  cent, 
during  the  first  year  of  existence.  Taking  the  mean 
of  the  somewhat  voluminous  tables  that  have  been 
published  upon  this  subject,  I  think  that  the  following 
percentage  will  fairly  represent  the  frequency  of  the 
disease  during  the  various  decades  of  life  : 


Before  tlie  age  of  1 1  years 
Between  11  and  20  years 
,,         21  and  40  years 
„         41  and  60  years 
Beyond  60  years 


53  per  cent. 
1'? 

20  „ 

11  „ 

4         ,,        or  probably  less.* 


Taking  the  jDercentages  of  a  large  number  of 
chronic  cases  only  the  following  results  are  obtained  : 

Before  the  age  of  11  years  .     25  per  cent. 

Between  11  and  20  years  .     10         ,, 

„         21  and  40  years  .     50         „ 

„         41  and  60  years  .11         „ 

Beyond  60  years        .  .4         ,, 

*  Mr.  Gay's  tables  show  a  much  larger  percentage  of  cases  in 
I^atients  over  sixty  years  of  age,  but  his  results  differ  so  widely 
from  those  iDublished  by  others  that  I  fancy  some  error  must  have 
crept  in. 


2i8  Intestinal  Obstruction.  [Chap.  x. 

A  comparison  made  between  these  two  tables 
shows  in  a  striking  manner  the  influence  of  age  upon 
the  chronicity  of  the  case.  It  seems  to  show  the 
great  frequency  of  the  acuter  forms  during  the  first 
ten  years  of  life,  and  of  the  chronic  forms  during  the 
period  of  active  adult  age. 

Previous  history. — In  the  previous  history  of 
cases  of  intussusception  there  is  little  to  note  that  is 
of  clinical  or  diagnostic  interest.  Indeed,  the  only 
circumstances  to  be  considered  in  such  a  history  are 
those  that  have  been  already  described  as  concerned 
in  the  etiology  of  the  disease.  Several  cases  have 
been  reported  in  which  there  is  little  doubt  but  that 
the  patients  had  had  previous  attacks  of  intussuscep- 
tion from  which  they  recovered  more  or  less  readily, 
Such  a  case  was  that  of  a  child,  aged  fifteen  months, 
who  was  suffering  from  an  intussusception  that 
protruded  at  the  anus.  Since  its  birth  the  child 
had  been  liable  to  attacks  of  "  colic,"  during  which  a 
mass  would  appear  in  the  epigastric  region  and 
subside  as  the  pain  passed  off.*  In  a  very  similar 
case,  in  the  person  of  a  girl  aged  nineteen,  who  died 
of  acute  intussusception,  there  was  a  history  of 
attacks  of  colicky  pain  which  probably  depended  upon 
invaginations  that  after  a  while  reduced  themselves. 

The  mode  of  onset  is  usually  sudden.  In 
acute  and  subacute  cases  a  sudden  mode  of  onset  is 
to  be  noticed  in  about  75  per  cent,  of  the  examples. 

In  chronic  cases  the  sudden  ajjpearance  of 
symptoms  is  noted  in  about  30  to  40  per  cent, 
of  the  recorded  instances.  The  mode  of  onset  is 
somewhat  influenced  by  the  nature  of  the  invagina- 
tion. In  ileo-colic  intussusceptions  the  commence- 
ment is  nearly  always  sudden,  while  in  the  colic 
and  rectal  varieties  it  is  more  frequently  gradual. 
The  symptoms  may  appear  (as  already  noted  when 
*-Nao  York  Med.  Journ.,  July,  1877. 


Chap.  X.  ]  I  NT  USS  USCEP  TION  :    SVMP  TOMS.  2  I Q 

speaking  of  tlie  etiology  of  the  disease)  during  perfect 
health.  They  may  come  on  abruptly  during  exe?.'cise 
or  while  at  rest,  and  even  during  sleep.  "^  Several 
cases  in  infants  displayed  their  first  evidences  while  the 
child  was  being  suckled.  As  a  rule,  in  both  the  acute 
and  the  chronic  cases,  the  fii'st  symjDtom  is  pain,  a 
symptom  the  characters  of  which  are  described  below. 
Yomiting  is  not  usually  among  the  initial  symptoms. 

Among  the  rarer  commencing  symptoms  the 
following  may  be  noted.  The  first  evidence  of  the 
invagination  may  be  simply  tenesmus  without 
abdominal  pain  ;t  or  tenesmus  with  much  straining  at 
stool.  In  one  case  of  gradual  origin  the  malady  was 
ushered  in  with  slight  colicky  pains,  with  much 
tenesmus  and  with  dysuria.  :j:  In  at  least  one  instance 
the  first  definite  signs  of  intussusception  were 
afforded  by  an  escape  of  blood  from  the  anus,  and 
shortly  after  by  the  projection  of  the  invaginated  gut 
through  the  sphincter.  § 

It  by  no  means  follows  that  cases  marked  by 
violent  and  abrupt  symptoms  at  the  commencement 
necessarily  take  an  acute  course.  They  frequently  do  ; 
although,  on  the  other  hand,  many  chronic  cases  have 
begun  with  very  urgent  manifestations.  As  one 
instance  of  the  latter  association  I  might  quote  a  case 
by  Hauf  ||  where  the  first  symptoms  were  those  of 
pain  so  violent  as  to  cause  the  patient  to  roll  upon 
the  gTonnd.  The  subsequent  course,  however,  of  the 
disease  was  linoferins:. 

Before  commencing  a  notice  of  the  separate 
symptoms   a   superficial   comparison    may    be   made 

*Patli.  Soc.  Trans.,  vol.  xi.,  page  109;  IMr.  Niuineley. 
tMr.  Pitts ;  St.  Thomas's  Hosp.  Eeports,  1882,  page  75. 
JOlile.    Mag.    fiir  die  gesam.    Heilk.   Rust.,   1817,   bd.   ii., 
s.  253. 

§  Mr.  H.  Marsh;  St.  Bart.'s  Hosp.  Eeports,  1876,  page  95. 
II  Heidelh.  Med.  Anal.,  1842,  bd.  8,  s.  428. 


2  20  Intestinal  Obstruction.  [Chap.  x. 

between  the  acute  and  the  chronic  cases.  In  the 
acute  form  of  the  disease,  the  symptoms  depend 
mainly  upon  strangulation  of  the  invaginated  bowel 
and  actual  obstruction  of  its  lumen.  They  are 
marked  by  paroxysmal  pain,  by  tenesmus,  by  the 
passage  of  bloody  mucus,  if  not  by  diarrhoea,  and  by 
the  presence  of  a  tumour.  In  chronic  intussuscep- 
tion a  patient  may  die  from  one  of  two  conditions. 
He  may  succumb,  emaciated  and  worn  out  by  the 
frequent  pain  or  vomiting  and  the  gross  interference 
with  the  functions  of  the  intestine ;  or  after  exhibiting 
for  some  time  the  evidences  of  chronic  invagination, 
he  may  die  of  an  acute  attack  supervening  upon  the 
chronic.  In  the  lingering  form  the  symptoms  are 
usually  very  ambiguous,  and  an  aspect  may  be 
assumed  by  the  case  that  may  be  lacking  in  all  the 
most  distinctive  si^ns  of  invagination. 

THE  ACUTE  AND  SUBACUTE  FORMS. 

Pain.— Pain,  as  already  stated,  is  usually  the  first 
symptom  of  intussusception.  It  is  also  one  of  the 
most  constant  and  conspicuous.  Sometimes  the 
initial  attack  of  pain  reaches  at  once  the  maximum 
of  that  felt,  and  after  its  subsidence  the  suffering 
becomes  moderate.  Usually,  however,  the  pain  in- 
increases  gradually  in  severity  up  to  a  certain  point, 
and  then  beijins  to  subside.  Durinor  the  time  that  the 
in\'agination  is  increasing  and  while  the  process  of 
strangulation  is  active  the  pain  may  be  acute,  but 
when  the  parts  have  become  well  fixed  by  adhesions, 
or  more  especially  when  gangrene  has  set  in,  it  com- 
monly becomes  greatly  modified  in  its  character. 
This  tendency  of  the  pain  to  become  less  at  a  certain 
stage  in  the  case  is  a  conspicuous  feature  in 
intussusception.  Tlie  pain  in  any  given  case  may 
commence  gradually  in  the  form  of  trifling  attacks  of 
colic  appearing  at  long  intervals  or  coming  on  only 


Chap.  X.]       Intussusception :  Symptoms.  221 

after  clefEecation,  or  a  violent  initial  attack  may  be 
preceded  for  a  while  by  a  definite  but  trifling  sense  of 
discomfort  in  the  abdomen.  The  form  of  in  vagina- 
tion  that  is  most  usually  associated  with  intense  pain 
at  the  onset  is  the  ileo-colic. 

The  pain  is  colicky,  and  its  great  feature  is  its 
occurrence  in  paroxysms.  Intermittent  pain,  as  has 
been  already  stated,  nearly  always  indicates  an 
incomplete  obstruction  in  the  intestine  and  in 
intussusception,  therefore,  it  may  be  expected  to  be 
well  marked.  The  pain  may  at  first  occur  at  long  in- 
tervals, during  which  the  patient  is  free  from  suffering. 
As  the  case  advances  the  intervals  become  shorter  and 
shorter.  In  the  acuter  forms  the  intervals  are  not 
marked.  The  patient  very  often  is  never  free  from 
pain  ;  but  here,  although  the  pain  is  continuous,  it  is 
broken  in  upon  by  definite  exacerbations.  The 
intervals  between  the  attacks  are  sometimes  very 
precise,  the  paroxysms  appearing  every  twenty  or 
thirty  minutes,  and  having  a  more  or  less  exact 
duration.  In  any  case,  as  the  intussusceptum  becomes 
congested,  its  neck  more  and  more  strangulated,  and 
its  lumen  narrowed,  the  pain  becomes  more  con- 
tinuous although  it  is  still  associated  with  exacerba- 
tions. When  the  j)aroxysms  are  marked  they  usually 
appear  suddenly  and  subside  suddenly,  although  to 
this  circumstance  there  are  many  exceptions. 

The  pain  in  intussusception  depends  upon  violent 
and  irregular  peristaltic  movement.  It  is  more 
severe,  as  a  rule,  in  cases  involving  the  small  than  in 
those  involving  the  large  intestine.  Some  of  the 
most  severe  instances  of  pain  have  been  in  the  ileo- 
colic varieties  and  in  invaginations  high  up  in  the 
small  intestine  where  the  muscular  coat  is  well 
developed.  It  has  been  said  that  the  intervals 
between  the  paroxysms  are  shorter  when  the  small 
gut  is  involved,  as  compared  with  the  colon.     This  is 


2  2  2  IntES TINA  L    ObS TR  UCTION.  [Chap.  X. 

often  true,  but  the  fact  depends  ratlier  upon  tlie 
<Treater  deiiTce  of  occlusion  met  with  in  the  lesser 
bowel  than  upon  the  anatomical  position  of  the  lesion. 
Everything  depends  upon  the  state  of  the  intussuscep- 
tion itself.  A  small  invagination  in  the  colon  may- 
cause  early  and  intense  pain,  while  on  the  other  hand 
an  ileo-caecal  invagination  may  actually  project  at  the 
anus  before  much  pain  has  been  produced. 

I  cannot  endorse  the  statement  that  the  move 
empty  the  bowel  the  less  the  pain.  Were  this  the 
fact  the  least  painful  cases  would  be  those  that  have 
followed  upon  diarrhoea.  The  reverse,  rather,  is  what 
is  usually  met  with.  It  is  well  known  that  when  a 
patient  has  a  sore  throat  it  is  more  painful  to  swallow 
a  teaspoonful  of  water  than  a  large  bolus  of  soft 
food  like  arrowroot.  The  large  mass  demands  but 
little  contraction  of  the  fauces  to  pass  it  along.  In 
one  well-marked  case  of  invagination  the  symptoms 
came  on  after  diarrhoea.  The  gut  in  this  instance 
may  be  considered  to  have  been  empty  ;  a  purge  was 
given  and  pain  of  the  severest  character  followed. 

In  a  few  cases  the  pain  has  been  described  as 
agonising,  but  as  a  rule  it  is  much  less  severe  than  in 
other  forms  of  acute  intestinal  obstruction.  In 
position  it  is  at  first  very  ill  defined,  but  as  the  in- 
vagination advances,  and  especially  as  a  definite 
tumour  develops,  the  pain  becomes  more  or  less  dis- 
tinctly localised  about  the  seat  of  the  lesion.  At  first 
the  abdominal  parietes  are  not  tender  on  pressure, 
and  are  flaccid,  or,  at  least,  not  in  a  state  of  tension. 
It  often  happens,  indeed,  that  pressure  over  the  more 
painful  part  relieves  the  patient's  suffering,  just  as 
cramp"  in  other  parts,  such  as  in  the  calf,  may  often 
be  relieved  by  pressure.  Muscles,  however,  that  have 
been  long  in  a  state  of  cramp  become  tender,  and  so 
in  intussusception  the  al)domen  in  time  usually  be- 
comes somewhat  tender  on  pressure,  especially  about 


Chap.  X.]       Intussusception:  Symptoms.  223 

the  site  of  the  invagination.  This  is  partly  the  result 
of  continued  irregular  muscular  action,  but  is  perhaps 
in  a  greater  extent  clue  to  the  engorgement  of  the  in- 
vaginated  parts  and  the  development  of  some  local 
peritonitis.  A  well  localised  tenderness  is,  in  the 
absence  of  a  definite  tumour,  a  valuable  guide  to  the 
position  of  an  intussusception.  Sometimes  the  pain 
has  been  relieved  when  the  patient  has  assumed  a 
peculiar  posture.  The  longer  the  case  lasts  the 
greater  is  the  tendency  for  both  the  pain  and  the  ten- 
derness to  become  diffused,  presuming  that  they  have 
been  previously  more  localised. 

Vomitiiag'  is,  in  intussusception,  by  no  means  so 
conspicuous  a  symptom  as  it  is  in  other  forms  of  acute 
intestinal  obstruction,  such  as  in  strangulation  by 
bands.  It  does  not  appear  so  early;  it  seldom  becomes 
excessive  or  very  distressing ;  it  is  less  often  stercora- 
ceous,  and  is  apt  to  fluctuate  considerably. 

Vomiting  is  more  constant  and  severe  in  acute 
cases  than  it  is  in  clironic.  In  about  three-fourths  of 
the  acuter  cases  it  appears  with  the  earliest  symp- 
toms, coming  on  either  with  the  pain  or  a  little  while 
after  it.  In  the  remaining  cases  it  appears  later, 
and  on  an  average  about  the  third  day.  Its  onset 
may  be  much  delayed,  as  in  a  case  where  laparotomy 
was  performed  on  the  eighteenth  day,  and  where 
vomiting  did  not  appear  until  the  fifteenth  day.  In 
chronic  forms  the  delay  may  be  still  greater,  and 
vomiting  may  not  set  in  until  a  few  days  or  hours 
before  death.  In  about  8  per  cent,  of  the  acute 
and  subacute  cases  vomiting  does  not  appear  to  have 
occurred  at  all  during  the  course  of  the  malady. 

There  is  often  great  irregularity  in  the  appearance 
and  character  of  the  sickness.  Indeed,  as  a  rule 
in  intussusception  this  symj)tom  is  marked  by  con- 
siderable fluctuations.  I  might  take  the  following 
as  a  fairly  marked  instance  :  In  a  case  of  ileo-colic 


224  Intestinal  Obstruction,  [Chap.  x. 

invagination,  fatal  on  the  fourteenth  day,  vomiting 
appeared  early  with  the  initial  pain.  It  persisted  for 
five  days.  During  the  sixth  day  the  patient  did  not 
vomit  at  all ;  on  the  seventh  day  the  sickness  re- 
turned in  a  more  severe  form  than  ever.  On  the 
eighth  it  was  again  much  better ;  wdiile  on  the  ninth 
it  became  feculent.'^  In  many  cases  the  vomiting, 
after  having  been  severe,  has  been  absent  for 
several  days  together.  In  several  examples  of  the 
acute  form  of  the  malady  that  I  have  collected  the 
patient  was  only  sick  once,  while  in  other  instances 
the  vomiting  appeared  at  long  and  irregular  intervals. 
The  attacks  of  vomiting  often  coincide  with  attacks 
of  pain.  In  one  case  of  acute  invagination  where  the 
sickness  had  ceased,  the  symptom  was  caused  to  reap- 
pear by  introducing  the  finger  into  the  rectum. f 

The  exammation  of  a  number  of  recorded 
cases  shows  that  the  vomiting  is  least  severe  and 
least  constant  in  those  cases  that  are  associated 
throughout  with  diaiThoea.  It  is  also  very  often 
slight  in  degree  in  those  instances  of  the  malady  that 
are  attended  by  distinctly  paroxysmal  pain.  In  other 
words,  the  sickness  is  least  troublesome  when  the 
lumen  of  the  bowel  is  still  patent.  Most  of  the  worst 
instances  have  been  in  cases  marked  by  early  and 
persistent  constipation,  excluding  from  that  term  the 
passage  of  blood  and  mucus  unmixed  with  faeces.  In 
any  case  the  sudden  cessation  of  diarrhoea  is  usually 
attended  by  an  increase  in  the  vomiting. 

In  many  instances  the  vomiting  gives  much  tem- 
porary relief.  This  is  especially  the  case  when  it 
ai)pears  at  long  intervals.  This  feature  is  more 
marked  in  the  vomiting  of  intussusception  than  in  any 
other  form  of  obstruction. 

The   vomited   matter   is    usually    alimentary    or 

*BulL  de  la  Soc.  Anat.,  1867,  page  136 ;  M.  Naudier. 
^Lancet,  vol.  i.,  1877,  page  273 ;  Mr.  Hansford. 


Chap.  X.]       Intussusception :  Symptoms.  225 

bilious.  Feculent  vomitinir  is  not  met  with  in  more 
tlian  25  per  cent,  of  all  cases  of  acute  or  suljacute  in- 
tussusception. In  chronic  cases  it  occurs  only  in 
about  7  per  cent.  In  the  acuter  cases  stercoraceous 
vomiting  is  in  nearly  every  instance  associated  with 
constipation,  or  at  least  with  the  passage  of  no  ftecal 
matter  in  the  discharge  from  the  anus.  It  is  met 
with  most  frequently  in  invaginations  about  the  ileo- 
C£ecal  region,  and  then  in  those  involving  the  lower 
extremity  of  the  small  intestine.  It  appears,  on  an 
average,  on  the  fourth  or  fifth  day.  It  often,  how- 
ever, does  not  ajjpear  for  a  week  or  a  fortnight,  or  not 
until  near  the  termination  of  the  case,  when  the  pro- 
gress of  the  malady  is  distinctly  subacute.  In  two 
or  three  instances  blood  has  appeared  in  the  vomited 
matter.  This  symptom  is  usually  met  with  in  chil- 
dren and  in  enteric  intussusceptions. 

On  the  whole,  it  may  be  said  that  vomiting  is 
most  marked  in  the  enteric  and  ileocolic  invagina- 
tions, less  marked  in  the  ileo-ctecal  forms,  and  least 
conspicuous  in  the  colic  and  rectal  varieties. 

Tlie  state  of  tlie  bowels  in  intussusception 
presents  some  very  distinct  characters.  As  a  result  of 
the  violent  peristaltic  action  excited  by  the  invagina- 
tion, diarrhcea  is  a  very  common  condition  ;  and  as  a 
consequence  of  the  great  engorgement  of  the  intussus- 
ceptum  it  happens  that  the  motions  passed  are  usually 
stained  with  blood.  When  the  lumen  of  the  bowel  be- 
comes so  occluded  that  no  more  faecal  matter  passes,  the 
evacuations  may  consist  simply  of  bloody  mucus. 

Constipation,  as  indicated  by  the  passage  of  no 
faecal  matter,  is  not  common  in  intussusception.  In 
the  majority  of  the  acute  and  subacute  cases  there  is 
some  diarrhoea  at  first  and  then  absolute  constipation 
towards  the  termination  of  the  case.  The  occurrence 
of  more  or  less  constipation  as  a  marked  feature  dur- 
ing the  jyr ogress  of  the  malady  does  not  pertain  to 
p— 12 


2  26  Intestinal  Obstruction.  [Chap.  x. 

more  than  30  per  cent,  of  the  cases.  Sometimes 
diarrhoea  continues  throughout  the  whole  course  of 
the  case,  being,  aa  a  rule,  more  marked  at  the 
commencement  than  the  end.  At  the  same  time  it 
may  be  noticed  that  a  severer  diarrhoea,  or  a 
diarrhoea  after  constipation,  may  precede,  attend,  or 
follow  the  elimination  of  a  gangrenous  intussuscep- 
tum.  Sometimes  a  loose  state  of  the  bowels  alter- 
nates with  some  constipation,  but  this  condition  is 
more  usual  in  the  chronic  forms  of  the  malady.  The 
diarrhoea  may  be  severe  ;  and  from  ten  to  twenty 
evacuations  may  pass  in  the  twenty-four  hours. 

The  occurrence  of  blood  in  the  stools  is  a  striking 
feature.  As  a  rule,  the  more  acute  the  case  and  the 
more  violent  the  strangulation,  the  more  conspicuous 
is  the  haemorrhage.  In  acute  cases  this  symptom  is 
present  in  about  80  per  cent,  of  the  examples.  It  is 
met  with  less  frequently  in  those  following  a  subacute 
course,  and  is  found  in  no  more  than  50  per  cent,  of 
tlie  chronic  cases.  It  is  perhaps  more  marked  in 
children  than  in  adults.  It  is  most  constant  in  the  ileo- 
colic varieties,  then  in  the  ileo-caical,  next  in  the 
colic,  and  is  probably  least  constant  in  enteric  invagi- 
nations. The  amount  of  blood  is  usually  not  exces- 
sive. The  liaemorrhage  may,  however,  be  so  profuse 
as  to  be  the  principal  cause  of  death. ^  As  already 
observed^  the  clots  of  blood  may  block  up  the  lumen 
of  the  intussusceptum  and  may  even  plug  the  bowel 
below  the  seat  of  the  invagination.  In  any  case  the 
symptom  is  usually  more  marked  at  the  commence- 
ment of  the  attack  than  during  its  later  progress. 
Bleeding  may,  however,  attend  the  evacuation  of  the 
intussusceptum. 

l*ciiesiiiiis  is  a  striking  symptom.  It  is  more 
commonly  met   with  in  acute  and  subacute  than  in 

*Le  Moyne,  loc.  cit. ,  page  23.    Med.  Times  atvd  Gazette,  vol.  ii., 
1865,  page  195.    Anier,  J  own.  Med.  Sciences,  vol.  xii.,  page  372. 


Chap.  X.]        Intussusception:  Symptoms.  227 

chronic  Ctases.  Indeed,  other  things  being  equal,  the 
more  chronic  the  case  the  less  fre(i[ucnt  is  the  a])])ear- 
ance  of  the  symptom.  I  find  that  in  acute  and  sub 
acute  forms  tenesmus  occurs  in  about  55  per  cent,  of 
the  exam})les.  Kafinesque  finds  an  account  of  the  oc- 
currence of  this  symptom  in  only  13  per  cent,  of  dis- 
tinctly chronic  cases.  The  mean,  therefore,  for  all 
forms  of  invagination  would  be  about  24  per 
cent.  Leichtenstern  in  his  able  monograph  gives 
this  mean  as  17'G  per  cent.,  but  I  cannot  help 
thinking  that  this  percentage  is  much  too  low.  It 
must  be  remembered  that  in  many  accounts  of  in- 
vagination re[)orted  from  a  pathological  point  of  view 
the  symptoms  are  often  im])erf ectly  given ;  and  many 
of  such  cases  can  hardly  but  be  included  among  Leich- 
tenstern's  statistics.  The  frequency  and  severity  of 
the  tenesmus  depend  mainly  upon  the  nearness  of 
the  intussusception  to  the  anus.  The  symptom  there- 
fore is  very  usual  in  rectal  and  colic  invaginations,  is 
common  in  the  more  extensive  ileo-CiX!cal  varieties,  and 
is  least  often  met  with  in  the  pure  enteric  forms. 
Leichtenstern  finds  94  cases  mai-ked  by  tenesmus  to 
be  thus  divided  :  eiiteric  foim  4,  ileo-ciecal  forms 
75,  colic  forms  15.  The  proper  value  of  these  figures 
can  be  ai)preciated  by  reference  to  the  table  showing 
the  relative  frequency  of  the  various  varieties  (page 
171). 

Tenesmus  is  usually  an  early  symptom  of  intus- 
susception, and  is  indeed  often  among  its  first  mani- 
festations. It  may  be  so  constant  and  so  severe  as  to 
cause  intense  distress,  as  in  a  case  re[)orted  by  Dr. 
Ballard.-^"  When  the  invagination  occupies  the 
rectum  or  sigmoid  flexure  the  tenesnuis  may  be  fol- 
lowed by  paralysis  of  the  sphincter  ani  whereby  a 
patulous  condition  of  the  anus  is  produced.  A  good 
example  of  this  complication  has  been  placed  upon 
*rath.  Soc.  Trans.,  vol.  xviii.,  18G7,  page  92, 


228  Intestinal  Obstruction.  [Chap.  x. 

record  bv  Mr.  Holmes.  It  occurred  in  a  man  a^ied 
forty,  who  had  a  rectal  invagination.  The  sphincter 
became  so  relaxed  that  several  fingers  could  be  intro- 
duced into  the  anus."^ 

Ociicral  symptoms.— Of  the  general  constitu- 
tional condition  of  the  patients  suffering  from  acute 
and  subacute  intussusception  little  need  l)e  said.  The 
condition  is  nearly  the  same,  although  differmg  a 
little  in  degree,  as  that  met  with  and  described  in 
connection  with  strangulation  by  bands. 

Collapse  is  usually  much  less  marked,  because  on 
the  whole  the  progress  of  the  case  is  less  acute  and  the 
pain  less  severe  than  in  obstruction  by  bands.  In 
oome  ultra-acute  cases  collapse  may  appear  early  and 
lead  on  to  death.  This  is  especially  the  case  with 
acute  invaginations  in  young  infants.  Leichtenstern 
has  only  been  able  to  collect  five  instances  of  death 
during  the  first  twenty -four  hours,  and  of  these  cases 
no  less  than  four  were  in  infants  not  over  one  year 
old. 

As  regards  the  temperature  it  will  be  below 
normal  in  cases  associated  w4th  shock.  In  the 
majority  of  the  cases,  and  especially  in  such  as  are 
subacute,  it  is  normal  or  a  little  above  normal.  It  is 
important  to  recognise  the  fact  that  there  may  be  a 
rise  of  temperature  in  intussusception  apart  from  any 
evidences  of  local  peritonitis.  As  a  good  illustration 
of  this  may  be  cited  a  case  recorded  by  Dr.  Eastes. 
It  concerned  a  little  girl  aged  eleven.  On  the  seventh 
and  eighth  day  of  the  symptoms  the  temperature 
reached  101-3.  On  the  evening  of  the  eighth  day  the 
invagination  was  reduced  by  means  of  foi"ced  enemata. 
On  the  ninth  day  the  temperature  was  97  '6.  The  child 
made  a  good  recovery. 

Thirst  is  by  no  means  so  frequently  complained 
of  in  invagination  cases  as  it  is  in  examples  of 
*  Path.  Soc.  Trans.,  vol.  viii.,page  177. 


ciiap.  X.]       Intussusception:  Symptoms,  229 

strangulation  by  bands.  This  circumstance  depends 
mainly  upon  tlio  ksss  copious  cliaractor  of  the  vomiting. 
When  th(3  vomiting  is  very  profuse  in  intussuscej)tion 
nnich  thirst  may  be  complained  of.  The  symptom, 
however,  in  a  marlced  form  is  quite  rare. 

The  quantity  of  urine  passed  may  be  diminished, 
for  the  same  reasons  that  obtain  in  other  forms  of 
acute  obstruction  of  the  bowels.  The  symptom 
is  rarely  present,  and  is  seldom,  if  ever,  so  marked 
as  in  examples  of  strangulation  by  band.  It  is 
limited  to  the  more  distinctly  acute  instances  of  the 
malady  when  it  does  occur. 

I  can  only  find  two  instances  of  intussusception 
where  stranguary  was  complained  of,  and  no  case 
associated  with  the  appearance  of  crauips  in  the  limbs. 

In  the  subacute  cases  the  ])atients  become  thin  and 
anaemic  and  often  much  wasted.  A  condition  readily 
induced  by  the  continued  digestive  disturbance,  the 
frequent  attacks  of  vomiting  and  pain,  the  loss  of 
appetite,  and  the  broken  rest. 

TITE    STATE    OP    THE    ABDOMEN. 

Tension  of  llie  silxloiiiiiRnI  wnlls  is  not  met 

with  in  inlussuscei)tion,  or  at  least  not  in  the  earlier 
stages.  It  appears  when  local  or  genei-al  peritonitis 
develops,  and  may  ])e  present  during  the  attacks  of 
pain,  especially  wlien  they  have  existed  for  some  time 
and  are  attended  by  tenderness  on  pressure. 

Mcteorisiu  is  also  rare  in  these  cases.  In  a 
marked  form  it  is  seldom,  if  ever,  met  with.  It  de- 
pends undoubtedly  upon  the  condition  of  the  bowels. 
It  is  found  in  instances  where  constipation  exists  and 
where  the  lumen  of  the  intestine  is  practically  oc- 
cluded. It  is  thus  most  commonly  met  with  towards 
the  end  of  the  attack.  When  diarrhoea  exists,  not 
only  is  no  meteorism  ])rcsent,  but  the  abdomen  is 
often,  on  the  contrary,  distinctly  sunken  in.     On  the 


23c>  Intestinal  Obstruction.  [Chap. x. 

cessation  of  the  diarrhoea,  the  symptom  may  develop. 
It  is  usually  quite  moderate  in  degree.  It  is  needless 
to  say  that  it  af)pears  to  a  gi-eater  or  less  extent  wher 
peritonitis  sets  in. 

The  "  sigiie  de  Dance  "  is  of  little  or  no  value. 
It  is  said  to  be  met  with  in  cases  where  the  ciecum  has 
become  invaginated,  as  in  the  ileo-c^ecal  forms  of  the 
disease,  and  consists  in  a  depression  about  the  right 
flank  or  right  iliac  fossa.  It  is  supposed  to  indicate 
the  displacement  of  the  caput  coli.  One  would  expect 
this  symptom  to  l)e  more  marked  in  chronic  cases,  yet 
out  of  tifty-three  examples  of  this  form  collected  by 
Rafinesque  the  "  signe  de  Dance  "  was  only  noted  in 
two  instances. 

A  tiiinoiir. — The  presence  of  a  tumour  formed  by 
the  invaginated  mass,  and  to  be  felt  either  through 
the  abdominal  parietes  or  rectum  is  of  great  diagnostic 
value  in  cases  of  intussusception.  It  is  to  be  dis- 
covered in  a  little  less  than  50  per  cent,  of  all  cases, 
and  would  appear  to  be  not  more  frequently  felt  in 
the  chronic  than  in  acute  forms.  Thus  Leichtenstern, 
taking  all  varieties  of  intussusception,  found  that  it 
was  met  with  222  times  in  a  total  of  433  cases. 
Rafinesque,  dealing  only  with  chronic  cases,  found 
24  examples  of  the  occurrence  of  a  tumour  in  53  re- 
corded instances. 

The  tumour  is  more  commonly  met  with  in  some 
anatomical  forms  of  invagination  than  in  otliers.  It 
is  most  frequently  associated  with  the  ileo-cfecal  and 
colic  varieties,  least  frequently  witli  the  enteric  and 
ileo-colic.  The  relative  frequency  in  the  different 
varieties  may  be  expressed  as  follows  :  In  the  ileo- 
csecal  form  it  occurs  in  61  per  cent,  of  the  cases  ;  in 
the  colic  in  52  per  cent.  ;  in  the  enteric  in  24  per 
cent.,  and  in  the  ileo-colic  in  23  per  cent. 

It  is  usually  more  distinct  in  children  than  in 
adults.     The  tumour  varies  in  size.      It   may  be  as 


Chap.  X.]      Intussusception  :  Symptoms.  231 

small  as  a  hen's  ^^^g^  or  it  may  attain  the  thickness 
of  tlio  adult  fore-arm.  It  is  cylindrical,  and  is  very 
commonly  doscrilxMl  as  sausage-shaped.  It  often 
shows  the  distinct  curve  of  the  intussusception.  As 
regards  length,  it  is  usually  short  and  sff^xy  rarely 
exceeds  six  inches.  This  limitation  in  length  does 
not  necessarily  correspond  to  the  length  of  the  in- 
vagination mass.  It  depends  rather  upon  its  position. 
The  tumour  is  not  evident  when  it  occupies  the  he- 
patic or  splenic  flexures  of  the  colon,  and  thus  the 
portion  that  can  bo  detected  cannot  well  exceed  the 
length  of  the  transverse  or  descending  colon,  or  of 
part  of  the  right  limb  of  the  large  bowel. 

It  has  assumed  the  appearance  of  a  double  tumour, 
one  part  having  been  felt  in  the  transverse  and  the 
other  in  the  descending  colon,  the  intermediate 
portion  in  the  splenic  flexui'e  not  being  evident.  In 
the  ileo-cajcal  variety  the  tumour  will  be  more  distinct 
the  nearer  the  mass  is  to  the  rectum.  While  in  the 
cjecum  and  lower  ascending  colon  the  tumour  must 
necessarily  be  small.  The  rarity  of  a  tumour  in  the 
ileo -colic  variety  is  explained  by  the  small  size  of 
those  invaginations  when  simple,  and  by  the  fact  that 
the  intussusceptum  is  composed  of  small  intestine 
enclosed  in  large. 

It  thus  happens  that  the  tumour  is  most  often  met 
with  over  the  descending  colon,  and  next  in  frequency 
over  the  transverse  colon.  Enteric  invaginations 
usually  form  a  tumour  in  the  csecal  region,  the  lower 
ileum  being  the  part  most  often  involved. 

The  tumour  varies  in  distinctness,  and  it  is 
seldom  that  all  parts  of  it  can  be  equally  made  out. 
It  usually  appears  fixed.  It  may  often,  however, 
especially  in  chronic  cases,  be  observed  to  change  its 
position,  to  now  advance  along  the  colon  in  the 
direction  of  the  anus,  and  now  to  return  by  the 
inverse   direction.  '   It   can   often   be  made  to  move 


232  INTESTI^^AL  Obstruction.  [Chap. x. 

under  tlie  use  of  enemata,  the  mass  being  forced  back 
towards  the  caecum.  This  can  only  occur  in  invagina- 
tions that  involve  the  colon.  The  progress  of  the 
in  vaccination  from  the  c?ecum  to  the  rectum  can  often 
be  distinctly  watched.  A  tumour  that  remains  long- 
stationary  in  the  csecal  region  probably  depends  upon 
an  ileo- colic  invagination. 

In  consistence  it  feels  hard  and  resisting.  Its 
density  may  vary  greatly.  During  attacks  of  pain  it 
may  be  large,  prominent,  and  haixl.  During  the 
intervals  it  often  becomes  less  distinct  and  softer. 
When  first  noticed  it  frequently  happens  that  it  is 
only  present  while  painful  peristaltic  movements  are 
going  on,  being  quite  absent  when  the  patient  is  free 
from  pain.  When  it  has  existed  for  some  time  it  is 
generally  tender  ;  but  in  earlier  periods  any  pain  that 
may  be  felt  in  it  is  ofteii  relieved  by  pressure.  In 
any  doubtful  case  an  examination  of  the  abdomen 
should  be  made  under  chloroform. 

M.  Homolle  rej^orts  a  case  where  three  invagina- 
tions existed  in  the  small  intestine,  which  gave  rise  to 
three  separate  tumours."^ 

The  importance  of  the  abdominal  tumour  in  the 
diagnosis  of  the  affection,  and  in  attempts  to  estimate 
the  condition  of  the  involved  segment,  is  considerable. 

In  no  case  should  a  tumour  be  pronounced  as 
absent  until  the  abdomen  has  been  examined  during 
a  paroxysm  of  i)ain.  When  present,  the  exact  site 
of  the  swelling  should  be  noted,  its  size,  its  outline, 
and  its  mobility. 

It  is  especially  to  be  observed  whether  the  mass 
increases  in  size  duiing  attacks  of  pain,  whether  it 
changes  its  position  during  attacks  of  pain,  and 
whether  it  is  tender  on  pressure. 

The  following  table  from  Leichtenstern's  mono- 
graph will  show  the  relation  between  the  tumour  and 
*Bull.  de  la  Soc.  Anat.,  1870,  page  260. 


Chap.  X.]      Intussusception :  Symptoms. 


233 


the  diffei'oiit  forms  of  intussusception,  together  with 
the  coTnj)arative  frequency   of  the  mass  in  different 

situations. 


Seat  of 

Intussusception. 

Seat  op  Tumour. 

6  s3 

Hi     f 

0 

0 
■A 

8 
6 

1  Unknown. 
Total. 

Ca3cal  region 

9 

0 

9 

4 

5    27 

Region  of  ascending  colon  .... 

1 

2 

1 

0 

3     7 

Ti-ansverso  colon 

12 

2 

4 

0 

1    19 

Region  of  descending  colon 

12 

4 

2 

1 

1!  20 

Region  of  sigmoid  flexure  .... 

25 

10 

3 

2 

12    52 

Tumour  in  the  rectum         .... 

10 

10 

0 

1 

10    31 

Tumour  piojecting  from  anus     . 

20 

12 

0 

1 

8    41 

Tumour  in  hypogastiium    .... 

0 

0 

3 

0 

0;        3 

Moving  of  tmnour  from  ascending  to  trans- 

verse colon  ...... 

1 

0 

0 

0 

0      ] 

Moving  of  tumour  from  transverse  colon 

to  sigmoid  flexure         .... 

8 

0 

0 

0 

0      8 

Moving  of  tumour  from  caecum  to  sigmoid 

flexure          

2 

0 

0 

0 

0      2 

Site  of  tumour  unknown     .... 

0 

1 

4 

0 

4!     9 

1 

Total 

100 

!1 

26 

9 

44  220 

Tumour  in  tlie  rectima. — It  will  be  seen  from 
the  above  table  that  in  thirty-one  instances  the 
tumour  was  felt  in  the  rectum,  while  in  forty-one  it 
projected  from  the  anus.  This  fcondition  is,  as  may 
be  surmised,  almost  limited  to  the  colic  and  ileo-csecal 
invaginations.  It  appears  much  more  frequently  in 
children  than  in  adults.  In  children,  moreover,  the 
tumour  reaches  the  rectum  much  more  quickly,  owing 
to  the  greater  mobility  of  a  child's  colon.  In  such 
patients  it  has  reached  the  rectal  region  by  the  second 
day  of  the  attack,  and  may  be,  as  already  stated,  one 
of  the  early  evidences  of  the  invagination.      Asa  rule, 


234  Intestinal  Obstruction.  [Chap.  x. 

the  tumour  appears  much  later,  on  an  average  (in 
acute  and  subacute  cases)  on  the  seventh  day.  In 
chronic  forms  the  average  date  for  the  appearance  of 
the  mass  in  the  rectum  is  the  fifteenth  day.  It  has, 
liowever,  appeared  as  late  as  the  third  and  fourth 
months,. and  in  one  case  as  late  as  the  seventh  month 
of  the  duration  of  the  symptoms.  The  protrusion  is 
usually  small  (being  about  three  inches  in  length),  and 
conical  in  shape.  It  may  attain  greater  length  (I 
have  seen  one  eight  inches  long),  and  cases  are 
reported  where  ten  and  twelve  inches  of  bowel  have 
projected  from  the  anus.  The  protruding  mass  is 
usually  deeply  congested  and  much  altered  in  structure. 
It  may  be  gangrenous.  The  intussusception  has,  how- 
ever, been  successfully  reduced  by  enemata,  insuffla- 
tion, or  laparotomy,  even  when  it  has  protruded  for 
some  time  at  the  anus."*  The  projecting  tumour  may 
present  at  its  apex  the  ileo-caecal  valve,  and  near  its 
extremity  the  orifice  of  the  appendix.  When  ex- 
amined by  the  finger  introduced  into  the  rectum,  the 
tumour,  before  it  has  prolapsed,  presents  tolerably 
characteristic  features  to  the  touch.  Its  swollen 
extremity  wdth  its  narrowed  lumen  has  been  many 
times  compared  to  the  os  uteri,  and  the  comparison 
is  a  very  suitable  one. 

The  tumour  wlien  in  the  rectum,  or  when  pro- 
truding beyond  it,  has  been  on  several  occasions  the 
cause  of  an  error  in  diagnosis.  It  has  been  mistaken 
for  prolapse,  for  rectal  polyp,  and  for  piles.  Un- 
fortunately the  error  has  extended  from*  the  dia- 
gnosis to  the  treatment,  and  the  mass  has  been  in- 
cised or  cauterised  and  even  cut  off.  There  are  some 
remarkable  cases  of  recovery  after  these  operations. 

*  The  best  case  is  the  well  known  one  of  Mr.  Hutchhison's. 
Here  the  symptoms  had  lasted  one  month  and  the  prolapse  had 
existed  for  fifteen  days.  The  bowel  was  reduced  after  laparotomy, 
and  the  child  recovered.     Med.-Chir.  Trans.,  vol.  Ivii.,  page  31. 


Chap.  X.]       Intussusception  :  Symptoms.  235 

In  one  the  patient  was  a  man  aged  sixty^  and  the 
tumour,  prolapsed  beyond  the  sphincter,  was  taken 
for  a  polyp  or  a  cancerous  growth.  It  was  re- 
moved en  masse  by  the  galvanic  wire  and  found  to 
be  a  piece  of  greatly  hypertrophied  ileum  with  the 
ileo-c?ecal  valve.  The  patient  recovered,  and  was 
relieved  of  a  con^ftipation  from  which  he  had  long 
suffered.*  In  another  case,  in  the  person  of  a  child 
aged  fifteen  months,  four  inches  of  intussuscepted 
bowel  were  cut  away  at  the  anus  without  any  evil 
followino'.t  In  a  third  instance  the  tumour  was  con- 
sidered  to  be  "  hsemorrhoidal,"  and  was  incised  to  the 
extent  of  one  inch,  laparotomy  was  then  performed, 
the  intussusception  reduced,  and  the  wound  in  the 
colon  stitched  up.     The  patient  died.  J 

On  the  other  hand,  in  cases  of  intestinal  obstruc- 
tion tumours  have  been  found  in  the  rectum  that 
have  been  mistaken  for  invaginated  masses.  Thus,  in 
a  case  reported  by  Dr.  Piatt,  a  child  aged  nine  had 
symptoms  of  obstruction  associated  with  some  of  the 
signs  of  intussusception.  High  up  in  the  rectum  a 
defined  soft  and  elastic  swelling  could  be  felt  which 
had  an  orifice  like  the  os  uteri.  In  a  few  days  it  was 
found  to  be  a  little  lower  down.  The  child  died. 
The  autopsy  revealed  a  stricture  of  the  small  intestine 
but  no  invao'ination.  The  tumour  was  a  remarkable 
false  diverticulum  in  the  rectal  wall,  into  the  orifice  of 
which  the  finger  had  been  passed. §  In  another  case,  in  a 
boy  aged  thirteen,  there  was  an  intussusception  of  the 
ileum.  Laparotomy  was  performed  with  a  fatal  result. 
During  life  there  was  felt  in  the  rectum  "  a  soft 
velvety  but  resisting  body  with  a  small  central  depres- 
sion,  suggestive  of  the  os  uteri.      Around  this,   and 

*  Boston  Med.  Journ.,  July  6,  1876. 

j-Weio  Vork  Med.  Journ.,  July,  1877. 

J  Mag.  fiir  gesam.  Heilk.  Rust.,  s.  253.     Berlin,  1817. 

%  Lancet,  vol.  i.,  1873,  page  42. 


236  Intestinal  Obstruction.  [Chap. x. 

between  it  and  the  rectum  wall,  the  finger  could  be 
swej^t  freely,  and  the  injection  tube,  when  guided  by 
the  finger,  could  be  passed  upwards  for  a  few  inches." 
The  autoi)sy  revealed  an  invagination  in  the  ileum 
nine  inches  from  the  caecum,  wdiile  the  rectal  tumour 
was  simply  a  mass  of  firm  blood-clot.* 

I  caii  only  find  two  cases  among  the  acute  or 
subacute  forms  of  intussusception  where  coils  of 
intestine  were  visible  through  the  abdominal  parietes. 
One  instance  occurred  in  Mr.  Morris'  patient,  to  whose 
case  allusion  has  just  been  made.  The  feature  was 
noticed  on  the  sixth  day  of  the  attack,  the  patient 
dying  on  the  eighth.  The  other  instance  concerned  a 
case  of  ileo-colic  invagination  in  a  girl  aged  seventeen.! 
The  symptom  appears  to  have  been  first  noticed  on 
the  eleventh  day,  death  taking  place  on  the  fourteenth. 
It  is  worthy  of  note  that  this  patient  was  emaciated 
by  chronic  phthisis  at  the  time  of  tlie  attack. 

THE    CHRONIC    FORMS 

By  an  arbitrary  division  those  cases  of  intus- 
susception are  considered  to  be  chronic  that  have 
lasted  for  more  than  one  month. 

Details  as  to  frequency  of  occurrence,  sex,  age, 
and  mode  of  onset  have  ah'eady  been  given ;  and  in 
the  account  of  the  acute  forms  a  general  notice  has 
been  taken  of  the  symptoms  of  invagination. 

It  remains  only  now  to  enter  into  certain  special 
points. 

Tlic  aiisttoiBiienl  form  of  intussusception  that  is 
most  often  met  with  in  chronic  cases  is  the  ileo-caical. 
It  forms  more  than  one-half  of  all  the  examples.  The 
enteric  form  is  the  variety  that  is  tlie  least  often 
chronic.     The  relative    proportion    is  thus  given    l)y 

*Patli.  Soc.  Trans,,  vol.  xxviii.,  page  131 ;  Mr.  Henry  Morris, 
fliull,  de  la  Soc.  Auat.,  18G7,  page  13G. 


Chap.  X.]      Intussusception  :  Symptoms.  237 

Rafinesqiie;  his  conclusions  being  based  upon  a  col- 
lection of  fifty-five  distinctly  chronic  cases.* 

Ileo-ctecal      ......  60  per  cent. 

CoHe 15        „ 

Enteric 15        „ 

Ileo-colic 10        „ 

100 

To  appreciate  the  full  value  of  this  talde  it  should 
be  compared  with  that  on  page  171.  which  deals  with 
intussusceptions  of  all  kinds  both  acute  and  chronic. 

The  clinical  featiu'es  of  chronic  intussusception 
are  often,  and  indeed  usually,  very  ambiguous.  No 
form  of  intestinal  obstruction  presents  so  many  con- 
fusing elements  in  the  diagnosis ;  no  form  has  led  to 
more  conspicuous  errors  in  the  right  appreciation  of 
the  nature  of  the  malady. 

Out  of  the  fifty-five  cases  collected  by  Eafinesque 
many  were  never  suspected  to  be  examples  of  intus- 
susception, and  no  less  than  twenty-seven  were  the 
sultjects  of  an  absolutely  incorrect  diagnosis.  Chronic 
intussusception  has  been  mistaken  for  fsecal  accumula- 
tion, for  rectal  polyp,  for  cancer  of  the  bowel,  for 
ulcer  of  the  stomach,  for  dyspej)sia,  for  chronic 
dysentery,  for  gastro-enteritis,  for  chronic  peritonitis, 
and  for  other  ailments  equally  remote  from  the  nature 
of  the  actual  disease. 

The  course  of  the  malady  may  extend  over  many 
months,  and  may  be  protracted  even  for  a  year.  In 
one  instance  there  are  good  reasons  for  believing  that 
the  intussusception  had  existed  for  more  than  a  year. 
Pohl  has  recently  reported  a  case  of  intussusception  in 

*In  the  follomng  account  of  clironic  invagination  in  its 
clinical  aspect  I  have  made  free  use  of  the  remarkable  mono- 
graph of  Eafinesque,  a  monograph  so  elaborate  and  exhaustive  that 
it  leaves  little  ground  untouched  and  available  for  subsequent 
writers. 


238  Intestinal   Obstruction.  [chap.  x. 

a  young  man,  which  he  affirms  had  existed  for  no  less 
a  time  than  eleven  years.  The  invagination  involved 
2-i  cm.  of  the  lower  ileum,  and  the  lumen  of  the  gut 
was  almost  ohliterated.  The  patient,  who  had  pre- 
sented intestinal  symptoms  during  the  eleven  years, 
died  of  an  acute  attack,  which  ended  on  the  fifth  day 
in  perforation.  * 

During  its  progress  the  malady  usually  follows  a 
most  irregular  course.  The  bowels  may  be  at  one  time 
constipated,  and  at  another  in  a  state  of  diarrhoea. 
There  may  be  violent  pain  one  day  and  none  the  next. 
Some  patients  are  troubled  by  severe  vomiting,  while 
others  are  never  sick.  In  some  cases  there  are  long 
intervals  of  freedom  from  sickness,  while  in  others 
there  are  no  such  breaks.  There  is  no  method  in  the 
ii-regularity  and  but  few  common  features  that  under- 
lie all  the  cases  and  that  may  serve  as  certain  signs. 

The  onset  of  the  malady  is  usually  a  little 
indefinite,  and  the  earliest  symptoms  are  often  ascribed 
to  indigestion,  to  mild  colic,  or  to  simple  irregularities 
in  the  bowels.  In  about  30  per  cent,  the  commence- 
ment has  been  abrupt,  the  case  suljsequently  assuming 
a  chronic  aspect.  In  any  case  pain  is  usually  the  iirst 
symptom.  The  ileo-colic  form  of  chronic  invagination 
usually  begins  suddenly. 

The  pain  that  occurs  during  the  progi-ess  of  the 
disease  is  paroxysmal.  Attacks  of  pain  may  appear 
several  times  a  day  or  only  once  in  the  twenty -four 
hou  rs.  Sometimes  days  and  c  ven  weeks  have  elapsed  be- 
tween the  paroxysms.  The  intervals  between  the  attacks 
are  seldom  regular,  and  when  the  pain  does  appear  at 
stated  times  the  occurrence  is  probably  due  each  time 
to  a  repetition  of  the  same  cause ;  as,  for  example, 
when  the  paroxysm  has  usually  appeared  at  night  after 
a  late  supper. 

As  the  malady  advances  the  intervals  between  the 
*  Prager  Med.  Wocheuschr.,  No.  21,  1883. 


Chap.  X.]       Intussusception  :  Symptoms.  239 

attacks  of  pain  become  shorter  and  the  pain  itself 
more  diffused.  In  the  less  protracted  cases  there  may 
be  almost  continuous  suffering,  marked,  however,  by 
exacerbations. 

The  pain,  when  jiresent,  iias  the  general  character 
described  when  dealing  with  the  acute  form  of  the 
disease. 

VoiiiUiii;^'  is  not  a  very  conspicuous  symptom.  In 
forty  of  Rafinesque's  cases  where  this  symj)tom  is 
mentioned  it  occurred  more  or  less  frequently  in 
twenty-four  instances.  In  four  instances  the  patient 
was  sick  at  rare  intervals,  in  seven  vomiting  did  not 
appear  until  within  a  few  days  or  hours  of  death,  and 
in  three  cases  there  was  an  (uitire  absence  of  vomiting 
throughout  the  progress  of  the  malady.  In  any  case 
the  attacks  of  sickness  were  very  rarely  continuous. 
Usually  they  appeared  at  ii'regular  intervals  coin- 
ciding with  the  attacks  of  pain  or  depending  upon 
some  alimentary  excess. 

The  duration  of  the  affection  appears  to  have 
little  effect  upon  this  symptom.  Age  has  some  in- 
fluence, since  nearly  all  the  cases  where  the  vomiting 
was  insignificant  or  absent  occurred  in  adults.  Vomit- 
ing is  most  constant  in  the  ileo-colic  and  enteric  forms, 
and  usually  appears  earlier  in  tliose  varieties  of  the 
disease  than  it  does  in  the  other  forms.  Feculent 
vomiting  is  met  with  in  less  than  7  per  cent,  of  the 
cases.  It  de|)ends  rather  upon  the  degree  of  ob- 
struction in  the  intestine  than  upon  the  seat  or  dura- 
tion of  the  intestinal  lesion. 

The  api»etit.e  usually  becomes  much  impaired, 
and  the  synq)toms  ai'e  often  aggi'avated  by  food.  In 
a  large  number  of  instances  it  showed  considerable 
fluctuations,  and  in  at  least  one  case  it  was  voracious.* 

The  state  of  the  bowels  is  most  variable. 
Natural  and  regular  stools  may  be  passed  during  the 
*  Path.  Soc.  Trans.,  vol.  x.,  page  160;  Dr.  Quain. 


240  Intestinal  Obstruction.         [Chap.  x. 

greater  part  of  the  disease,  or  there  may  be  long- 
continued  diarrhoea,  or  marked  constipation,  or  alter- 
nations between  the  two  last  named  conditions.  In- 
deed, the  only  certain  feature  in  the  state  of  the 
bowels  in  chronic  invagination  is  the  feature  of  un- 
certainty. On  the  whole,  a  tendency  to  diarrhoea  is  the 
most  common  condition,  and  a  noi'mal  state  of  the  bowels 
the  most  rare.  From  an  examination  of  forty- six  cases 
Eafinesque  obtained  the  following  results  :  Motions 
normal  or  nearly  so,  seven  cases ;  alternations  of  con- 
stipation with  diarrhoea,  eleven  cases ;  predominance 
of  constipation,  twelve  cases ;  and  predominance  of 
diarrhoea,  sixteen  cases.  Constipation  is  most  marked 
in  the  enteric  forms,  diarrhoea  in  the  ileo-ctecal,  and 
alternations  between  these  two  conditions  in  the  colic 
and  rectal  varieties. 

Blood  is  passed  with  the  stools  in  about  50  per  cent, 
of  the  cases,  while  tenesmus  is  present  in  1 3  per  cent. 

In  chronic  invagination  the  bowels  usually  respond 
to  the  action  of  aperients.  Tliese  drugs  sometimes 
give  much  relief,  but  more  often  provoke  at  least  a 
temporary  aggi-avation  of  the  symptoms. 

In  any  case  of  long-standing  intussusception  a 
certain  degree  of  persisting  obstruction  must  exist  in 
the  intestine.  As  a  result  of  this,  the  bowel  above 
the  invagination  becomes  hypertrophied  by  excessive 
development  of  its  muscular  wall.  The  patients,  on 
the  other  hand,  usually  emaciate,  and  the  anterior 
abdominal  parietes  of  course  share  in  the  general 
wastmg.  Thus  it  happens  that  coils  of  intestine  are  very 
often  to  he  seen  in  movement  beneath  the  belly  wall,  a 
circumstance  that  will  be  most  distinct  when  vigorous 
and  irregular  peristaltic  waves  are  passing  along  the 
disordered  intestine.  Tliere  are  few  forms  of  chronic 
obstruction  where  this  feature  is  more  marked  than  it 
is  in  the  present  class  of  cases,  and  it  serves  as  a 
valuable  factor  in  the  diairnosis. 


Chap.  X.]  JNTUSSUSCEPTION :    SYMPTOMS.  24 1 

The  general  eoiiclitioii  of  the  patients  in 
chronic  invagination  shows,  as  may  be  imagined, 
consideraljle  variation.  In  the  early  periods  of  the 
disease,  and  in  the  intervals  between  attacks  of  pain, 
they  may  appear  to  be  in  fair  health.  In  time,  how- 
ever, they  usually  become  anaemic  and  emaciated. 
Tliey  are  worn  out  by  the  frequent  pain,  and  exhausted 
by  the  vomiting  and  diarrhoea.  Some  die  of  an  acute 
attack  that  suddenly  appears  and  puts  an  end  to  the 
case.  Others  die  simply  of  exhaustion  and  marasmus. 
A  few  succumb  to  perforative  peritonitis,  and  a  small 
number  to  effects  depending  upon  the  spontaneous 
elimination  of  the  intussusceptum. 

With  regard  to  the  state  of  the  abdomen,  little 
can  be  added  to  what  has  been  said  when  speaking  of  the 
acute  form  of  the  malady.  As  a  rule  the  abdominal 
walls  remain  flaccid  and  present  no  abnormal  feature. 
When  a  long  continued  diarrhoea  exists  with  emacia- 
tion they  may  be  retracted.  When  marked  constipa- 
tion exists  there  may  be  some  meteorism,  which  will, 
however,  always  be  moderate.  Tenderness  on  pressure 
is  very  seldom  to  be  noticed  except  in  cases  that  are 
associated  with  peritonitis. 

As  already  stated,  a  tumour  is  to  be  found  in 
about  one-half  of  the  cases.  Its  characters  have  been 
fully  described  above. 

Among  the  fifty-five  cases  collected  by  Kafinesque, 
the  tumour  Avas  felt  in  the  rectum  in  seven  instances, 
and  had  protruded  beyond  the  sphincter  in  nine.  Thus 
it  will  be  seen  that  in  chronic  cases  the  invaginated 
mass  reaches  the  rectum  in  about  32  per  cent,  of  the 
cases. 

In  Rafinesque's  series  the  mass  was  discovered  in 
the  rectum  on  about  the  fifteenth  day  in  three 
instances,  and  at  the  third,  fourth,  fifth,  and  seventh 
month  respectively  in  the  remaining  four  examples. 

Q— 12 


242 


CHAPTER    XL 

THE    COURSE   AND    PROGNOSIS    OF    INTUSSUSCEPTION. 

As  has  been  already  remarked,  the  course  of  an  in- 
tussusception may  be  either  ultra-acute,  acute,  sub- 
acute, or  chronic  (page  215). 

The  relative  frequency  of  these  diflferent  forms,  as 
ascertained  from  an  examination  of  the  fatal  cases, 
may  be  expressed  as  follows  : 

Acute 48  per  cent. 

Subacute         .         .         .         .         .     34        ,, 
Chronic  .         ,         .         ,         .18        ,, 

100 

The  ultra-acute  form  is  extremely  rare.  Leich- 
tenstern  met  with  only  five  examples  of  it  among 
nearly  270  fatal  cases. 

The  site  of  tlie  invagination  greatly  influences  its 
course.  Thus  the  enteiic  and  ileo-colic  forms  are 
usually  acute  or  subacute,  the  great  majority  of  the 
exami)les  of  both  these  varieties  terminating  within 
the  first  fourteen  days  of  the  attack.  Colic  and  rectal 
invaginations  are  more  often  chronic  or  subacute 
than  acute. 

Ileo-csecal  intussusceptions,  being  the  most  common 
form  of  the  malady,  are  met  with  in  all  tlie  grades  of 
the  affection.  Three-fourths,  however,  of  the  cases 
are  either  subacute  or  chronic.  Attention  has  already 
been  drawn  to  the  fact  that  GO  per  cent,  of  the 
examples  of  chronic  invagination  belong  to  the  ileo- 
csecal  variety. 

Tlie  age  of  the  patient  also  greatly  influences  the 
progress  of  the  aflection.     This  is  well  demonstrated 


Chap.  XL]      Intussusception:  Prognosis.  243 

in  the  subjoined  analysis  of  269  fatal  cases  collected 
by  Leiclitenstern.  It  shows  that  invagination  in  the 
very  young  lias  a  great  disposition  to  run  an  acute 
course.  Four  out  of  five  ultra-acute  cases  occurred  in 
children  not  over  a  year  old  ;  and  no  less  than  79 
out  of  129  acute  cases  occurred  also  in  patients  who 
were  not  more  than  twelve  months  of  age. 

The  general  mortality  of  intussusception  is  about 
70  per  cent.  Leiclitenstern  has  pointed  out  that  the 
malady  is  somewhat  more  fatal  in  females  than  in 
males,  and  gives  the  following  as  the  results  obtained 
from  his  statistics  :  Males,  mortality  68  per  cent.  ; 
females,  70  per  cent. 

The  ultra-acute  cases  are  all  fatal,  the  patients 
dying  of  shock  within  a  comparatively  short  time  from 
the  commencement  of  the  attack."^  A  very  high 
mortality  runs  through  the  acute  cases,  especially 
through  such  as  occur  in  young  children.  Most  of  the 
cases  of  recovery  are  met  with  in  the  subacute 
variety  of  the  malady.  The  mortality  among  dis- 
tinctly chronic  cases  is  again  high.  Out  of  fifty-nine 
chronic  cases  collected  by  Eafinesque  there  vvere  no 
less  than  fifty-one  that  terminated  fatally. 

The  extremely  fatal  character  assumed  by  intus- 
susception in  infants  under  one  year  old  is  well 
illustrated  in  the  subjoined  table.  In  over  80  per 
cent,  of  the  fatal  cases  death  occurred  before  the 
seventh  day. 

Ill  children  that  are  a  little  older  the  fatal  termi- 
nation usually  takes  place  towards  the  end  of  the  first 
weekj  or  the  commencement  of  the  second.  In  adults 
death  usually  takes  place  during  the  course  of  the 
second  and  third  weeks  ;  many,  however,  dying  after 
the  malady  has  become  chronic. 

According  to  Leiclitenstern,  the  deaths  between  the 

*  As  a  good  example,  see  Lancet,  vol.  i.,  1882,  page  604.  Child 
lived  thirteen  hours. 


244 


InTES  TINA  L    ObS  TR  UC  TION. 


[Chap.  XI. 


ages  of  eleven  and  sixty  years  are  met  with  in  the 
different  anatomical  varieties  in  the  following  propor- 
tions :  The  ileo-caecal  forms,  71  per  cent.  ;  enteric, 
57 "8  per  cent.  ;  colic,  70-9  per  cent. 


Ages  of  Patients. 

Time  of  Death. 

u 

CO* 

o 

to 

t 

CO 

of 
U 

o 
I— 1 

o 
o 

O 

o 
o 

o 

CO 

o 

tH 

-p 

+3 

4J 

-*J 

-tJ 

o 

a 

(N 

^ 

1-1 

r-l 

1-1 

< 

P 

The  1st  day 

4 

0 

0 

0 

1 

0 

0 

0 

5 

The  2nd  day  . 

18 

4 

2 

1 

1 

0 

0 

0 

26 

The  3rd  day    . 

26 

2 

1 

2 

0 

1 

0 

3 

35 

The  4th  to  the  7th  day 

35 

10 

7 

4 

3 

4 

1 

4 

68 

In  the  2nd  week     . 

10 

6 

4 

10 

13 

5 

1 

2 

51 

In  the  3rd  week 

2 

2 

1 

3 

8 

0 

0 

2 

18 

In  the  4th  week 

2 

1 

1 

0 

5 

4 

1 

1 

15 

In  the  2nd  and  3rd  months 

2 

1 

2 

5 

8 

5 

0 

4 

27 

In  the  4  th  and  5th  months 

1 

2 

0 

0 

7 

1 

0 

0 

11 

In  the  6th  and  7th  months 

0 

0 

0 

0 

1 

0 

0 

2 

3 

In  the  8th  month    . 

0 

1 

1 

0 

1 

0 

0 

0 

3 

In  the  9th  month    . 

0 

0 

0 

0 

1 

0 

0 

0 

1 

In  the  10  th  or  11th  month 

0 

0 

0 

0 

2 

0 

0 

1 

3 

After  1  year   . 

0 

0 

0 

0 

0 

0 

1 

1 

2 

After  2  years . 

0 

0 

0 

0 

0 

1 

0 

0 
20 

1 

Total     .          .   J10029  19 

25 

51 

21 

4 

269 

Illetliocls  of  spontaneous  cure.— In  a  great 
many  instances  intussusceptions  Lave  been  cured  by 
treatment,  some  have  been  successfully  reduced  after 
laparotomy  had  been  performed,  others  have  been  un- 
folded by  means  of  enemata  and  insufflation  of  air. 

With  these  cases,  liowever,  we  have  at  present  no 
concern,  and  liave  to  deal  only  with  instances  where 
the  invagination  has  cured  itself. 

Cases  of  spontaneous  cure  may  be  divided  into 
two    distinct   categories  :    1.    Those    that    occur    in 


Chap.  XL]        IXTUSSUSCEPTIOy :    PROGNOSIS.  245 

invaginations  that  are  still  reducible.  2.  Those  that 
occur  in  invaginations  that  are  quite  irreducible. 

To  the  first  category  belong  instances  of  sponta- 
neous reduction.  Of  the  existence  of  this  mode  of  cure 
there  can  be  little  doubt,  although  its  occurrence  uiust 
be  a  matter  of  extreme  rarity.  There  are  se^^eral  instances 
reported  of  fatal  intussusception  in  which  the  patient 
had  had  one  or  more  previous  attacks  which  in  all  points, 
save  in  duration,  resembled  the  earlier  stages  of  the 
fatal  attack.  There  is  every  reason  to  suppose  that 
such  previous  attacks  were  due  to  the  formation  of  intus- 
susceptions that  underwent  spontaneous  reduction. 

I  think,  moreover,  that  some  of  the  cases  of  sup- 
posed cure  of  invagination  by  large  doses  of  opium, 
administered  promptly,  may  have  been  instances  of 
spontaneous  reduction ;  the  curative  movement  being 
rendered  more  easy  by  the  state  of  nerve  repose  in- 
duced by  the  sedative. 

There  are  one  or  two  cases  where  patients  have 
died  after  ha^ong  presented  many  of  the  symptoms  of 
invagination,  and  where  after  death  nothing  was 
found  save  a  piece  of  small  intestine  shrunken 
and  congested.  Such  cases  might  well  have  been  in- 
stances of  the  spontaneous  reduction  of  an  enteric 
invagination,  although  they  are  described  as  examples 
of  death  from  "spasm,"  or  from  paralysis  of  a  portion 
of  the  bowel.  "^  A  case  reported  by  Mr.  Gay  affords 
probably  a  little  more  dii^ect  evidence  concerning  this 
matter.  The  patient  was  a  woman,  aged  thirty-eight, 
who  was  admitted  into  hospital  with  symptoms  of 
obstruction.  The  symptoms  had  appeared  suddenly ; 
there  was  fixed  and  localised  pain,  a  hard  tumour  to 
the  left  of  the  umbilicus,  constipation  and  vomiting. 

*  See  case  recorded  by  Henrot ;  Des  Pseudo-etranglements, 
page  53.  Paris,  1865.  Also  case  by  Travers ;  Inquiiy  into  the 
Process  of  Nature  in  repairing  Injuries  of  the  Intestines,  page  211, 
London,  1812. 


246  Intestinal  Obstruction.        [Chap.  xi. 

The  symptoms  in  a  short  while  passed  off  suddenly. 
The  patient  was  phthisical,  and  died  in  two  days  of 
pulmonary  hsemorrhage.  The  autopsy  revealed  a 
contraction  of  a  limited  portion  of  the  ileum,  and  the 
gut  presented  distinct  evidences  of  recent  constriction. 

It  may  be  surmised  that  spontaneous  reduction 
can  only  occur  in  quite  recent  cases,  and  probably 
only  in  the  enteric  form  of  invagination.  A  remark- 
able case  recorded  by  Rilliet  would  appear  to  point  to 
the  possibility  of  spontaneous  reduction  in  cases  of 
some  standing,  Rilliet's  patient  was  a  boy,  aged  ten, 
who  was  taken  on  July  1st  with  abdominal  pains.  On 
August  4tli  he  A'omited  ;  August  5th  and  6th  were 
marked  by  the  appearance  of  severe  intermittent 
attacks  of  colic,  and  evidences  of  a  painful  tumour  in 
the  right  flank.  Black  fetid  stools  were  passed.  The 
attacks  of  pain  were  followed  by  intervals  of  complete 
ease.  By  the  9th  the  tumour  had  become  softer 
and  less  defined.  Diarrhoea  set  in  on  the  10th, 
the  stools  containing  a  little  blood.  The  tumour 
gradually  diminished  and  disappeared  and  the  child 
got  well.*  Rafinesque  reports  in  his  monograph  a 
somewhat  similar  case.  In  both  these  cases  it  would 
have  to  be  shown  that  the  obstruction  Avas  not  due  to 
the  impaction  of  faeces  or  undigested  food  l)efore  they 
could  be  accepted  as  intussusceptions. 

To  the  second  category  belong  two  kinds  of  case. 
In  one  a  fiecal  fistula  is  formed  in  the  bowel  above 
the  intussusception.  In  the  other,  spontaneous  cure  is 
brought  about  by  elimination  of  the  invaginated  bowel. 

The  formation  of  a  fsecal  fistula  must  be  ex- 
tremely rare.  I  have  only  been  able  to  find  one 
example  of  such  a  mode  of  relief.  The  case  is  re- 
ported by  Bruchet,  and  concerns  a  man  of  sixty-seven, 
who  for  three  or  four  months  before  his  death  passed 
fsecal  matter  with  his  urine.  The  autopsy  showed  a 
*  Gazette  des  Hdpitaux,  1852. 


Chap.  XI.]     Intussusception :  Prognosis.  247 

short  intussusception  of  the  colon  into  the  sigmoid 
flexure  with  above  it  a  fistulous  opening  into  the 
bladder.*  It  will  be  understood  that  should  a  faecal 
fistula  (due  to  ulceration  above  the  obstruction)  form 
and  make  its  outer  orifice  in  the  integuments,  an 
artificial  anus  may  be  produced  that  could  gi\'e  per- 
manent relief. 

Elimination  of  the  invaginated  boAvel  by  gangrene 
is  the  only  common  form  of  spontaneous  cure.  The 
account  of  the  pathology  of  the  process  has  already 
been  given  (page  196).  For  statistics  on  the  matter 
we  have  again  to  turn  to  Leichtenstern,  whose  collec- 
tion of  cases  is  greatly  in  excess  of  that  made  by  any 
othei"  author. 

►Spontaneous  elimination  occurs  in  about  42  per 
cent,  of  all  cases.  It  is  a  little  influenced  apparently 
by  sex,  occurring  in  54  per  cent,  of  the  female  cases 
and  in  31  per  cent,  of  the  cases  in  males. 

It  is  greatly  influenced  by  the  position  of  the  in- 
tussusception. 

Thiis,  in  the  ileo-c.Tcal  invaginations 

it  occurred  in  .         .         .         .20  per  cent,  of  the  cases. 

In  colic 28  ,,                  „ 

In  enteric 61  ,,                   ,, 

Still  more  conspicuously  is  spontaneous  elimination 
influenced  by  age,  being  extremely  rare  in  children 
under  two  years  of  age. 

Leichtenstern's  statistics  upon  this  point  yield  the 
following  results  : 

In  the  first  year  of  age  spontaneous 

elimination  occurred  in  .  ,2  per  cent,  of  tl\e  cases. 

Between  the  2nd  and  5th  year  .  G               ,, 

,,              6th    „     10th   ,,  .  a8               ,, 

11th    „     40th   „  .  40 

„            41st     „     60th   „  .  44 

Above  the  age  of  60  years     .  .  46              ,, 

*  Revue  Mensuelle  de  Med.  et  de  Cbir.,  1S7?^,  tome  ii.,  pao-e 
255. 


248 


JnTES  TINA  L    ObSTRUC  TION. 


[Chap.  XI. 


The  period  of  time  in  the  course  of  the  malady  at 
which  elimination  occurs  is  fully  shown  in  the  follow- 
ing table  also  from  the  same  monograph. 


3ontan< 

30US  elmnnation  occ 

urrea  : 

At  the 

end  of  3  days  in 

.      1 

case 

4  „ 

5  to  7  days  in 
8  to  10      „ 

.      2 
.       8 
.     14 

5) 

11  to  14     „ 

.     35 

After  the  3rd  week,  in 

.     34 

4th      „          _         . 
2nd  month,  in 

.     12 
9 

„        4th         „ 
„       6th 
After  about  one  year,  in 

.       3 
.       3 
.       3 

(?) 

It  must  not  be  supposed,  however,  that  when 
spontaneous  elimination  has  occurred  cure  and  recovery 
must  necessarily  follow. 

Over  40  per  cent,  of  the  patients  who  have  been 
the  subjects  of  elimination  of  the  bowel  die  from 
effects  directly  coiniected  with  the  intestinal  lesion  or 
with  the  elimination  process  itself.  The  mortality 
after  separation  is  a  little  lower  in  colic  invaginations 
than  it  is  in  the  remaining  forms,  and  is  con- 
sj)icuously  affected  by  the  age  of  the  patient.  If  one 
excepts  the  very  young,  it  may  be  said  that  the  older 
the  patient  the  greater  becomes  the  probability  that 
elimination  of  the  bowel  will  be  followed  by  death. 
In  patients  between  eleven  and  twenty  yeai's  of  age 
the  deatlis  after  spontaneous  separation  are  only  28  per 
cent. ;  in  those  between  twenty-one  and  forty  years 
32  per  cent.,  between  forty-one  and  fifty  the  percen- 
tage of  deaths  rises  to  3(3,  and  in  patients  between 
fifty-one  and  sixty  years  of  age  to  50  per  cent.  In 
])atients  above  sixty  years  of  age  the  mortality  is  as 
higli  as  85  per  cent. 

It    only   remains   now   to  consider  what  are  the 


Chap.  XL]     Intussusception  :  Prognosis.  249 

modes  of  death  after  spontaneous  elimination  of  the 
gangrenous  intestine. 

In  the  first  pkice  it  often  happens  that  the  separa- 
tion is  in  a  sense  premature  and  occurs  Lefoi'e  the 
parts  about  the  neck  of  the  mass  have  become  securely 
fused  together.  After  tlie  intussusceptum  has  been 
removed  a  perforation  or  rupture  occurs,  through 
which  f?ecal  matter  escapes  into  the  peritoneum,  lead- 
ing to  a  fatal  peritonitis. 

Or  the  fusion  of  the  parts  about  tlie  neck  may  be 
perfect  but  slight.  The  gangrenous  segment  in  its 
passage  along  the  intestine  blocks  the  canal :  some  ob- 
struction occurs  :  the  gut  above  the  obstructed  point 
becomes  distended,  and  a  rupture  occurs  along  the 
line  of  se2:)aration  of  the  gangrenous  intestine. 

In  another  set  of  cases  persistent  ulceration  re- 
mains about  the  elimination  line.  This  may  lead  to 
chronic  diarrhoea,  which  may  in  time  prove  fatal,  or 
may  cause  death  much  more  readily  Ijy  producing  a 
perforation.  This  and  like  perforations  may  either 
open  upon  the  peritoneal  surface  or  into  the  subperi- 
toneal tissue.  In  the  latter  instance  a  large  faecal  abscess 
is  produced  and  the  fatal  issue  more  or  less  delayed. 

A  part  of  the  intussusceptum  may  remain  and  may 
lead  to  a  new  invagination,  which  in  its  turn  may 
prove  fatal. 

Some  patients  die  of  haemorrhage  incident  to  the 
separation  of  the  gangrenous  gat.'^  Others  perish 
from  pysemia,  and  of  this  form  of  death  Mr.  Holmes 
has  recorded  an  excellent  example,  f 

Hafinesque  has  discovered  two  recorded  cases  of 
gangrene  of  one  of  the  lower  limbs  following  upon 
eliuiination  of  invaoinated  bowel.  In  both  these  in- 
stances  it  is  probable  that  the  result  was  brought 
about  by  thrombosis  of  the  iliac  veins. 

*  Amer.  Joiirn.  Med.  Sciences,  vol.  xii.,  page  372. 
f  Path.  Soc.  Trans.,  vol.  xix.,  page  207. 


250 


Intes  tin.  I L  Obs  tr  uc  tion. 


[Chap.  XI. 


It  is  said  that  stricture  of  the  intestine  may 
follow  from  cicatrisation  at  the  line  of  elimination, 
and  that  the  stricture  so  produced  may  cause  in  its 
turn  fatal  obstruction.  Such  an  occurrence  must  be 
very   rare.      It   is  true  that  some   narrowing  of  the 


Fig.  45.— Contraction  of  Colon  after  the  separation  of  an  Intussi\sception. 

a,  ileum  ;  h,  colon  ;  c,  CKcmn  ;  d,  seat  of  contraction. 

parts  may  occur  after  the  separation,  as  is  well  shown 
in  Fig.  45.*  Recovery  following  ui)on  elimination  is 
comparatively  common,  yet  I  cannot  find  in  any  of  the 
museums  in  London  a  straightforward  case  of  stricture 
of  a  marked  kind  following  upon  intussusception,  nor 
have  I  discovered  any  recorded  cases  (save,  perhaps, 

*  College  of  Surgeons  Museum,  No.  1,377.    For  another  ex- 
ami»lo,  .srrlSr.  Hare's  case  ;  Path.  Soc.  Trans.,  vol.  xiii.,  page  86. 


Chap.  XI.]     Intussusception:  Prognosis.  251 

one  mentioned  belo^v)  where  such  a  circumstance  has 
without  doubt  occurred.  It  would  appear,  then,  that 
stricture  of  the  intestine  of  a  grade  sufficient  to  cause 
fatal  obstruction  must  be  excessively  rare  as  a  result 
of  the  elimination  of  the  gut  in  invagination. 

In  one  case  of  stricture  of  the  lesser  bowel  that  is 
supposed  to  have  followed  invagination,  there  is  no 
history  of  a  piece  of  gut  having  been  passed,  nor  indeed 
any  evidence  that  the  patient,  a  woman  of  thirty- 
eight,  had  ever  had  intussusception.  This  patient, 
moreover,  had  a  cicatricial  strictirre  in  her  gullet,  and 
a  cicatrix  in  her  stomach  that  had  o-reatlv  deformed 
that  viscus.  In  the  absence  of  some  complete 
evidence  it  may  be  suggested  that  the  cicatrix  in  the 
jejunum  was  due  to  the  same  cause  that  produced  the 
two  other  cicatrices."^  The  solitary  case  alluded  to 
above  is  placed  on  record  by  Dr.  Fuller.  It  concerns 
a  patient,  aged  twenty-one,  who  died  of  subacute  in- 
tussusception of  the  ileum.  When  twelve  years  old 
she  had  had  a  severe  attack  of  colic  attended  by 
vomiting  and  much  pain  in  the  iliac  region.  The  symp- 
toms subsided  in  seven  days.  She  had  since  then  been 
much  troubled  with  constipation.  The  autopsy  re- 
vealed no  less  than  thirty  polypoid  growths  in  the  lesser 
bowel.  Four  and  a  half  feet  above  the  caecum  the  ileum 
presented  a  cicatricial  stricture,  as  if  from  an  ulcer, 
the  bowel  here  resembling  the  ileo-c^cal  valve.  It  may 
in  this  case  be  surmised  that  the  attack  at  the  age  of 
twelve  was  due  to  an  intussusception,  brought  about 
perhaps  by  a  polvp,  and  that  the  cicatrix  had  resulted 
from  the  separation  of  the  involved  part. 

This  conclusion,  however,  can  be  nothing  more 
than  a  surmise. 

Among  the  signs  that  mark  the  separation  of 
gangrenous  bowel  are  the  following  :  The  evacua- 
tions commonly  become  exceedingly  foul,  blood  often 
*  Dr.  Biistowe  ;  Path.  Soc.  Trans. ,  vol.  xx. ,  page  ISO. 


252  Intestinal  Obstruction.       [Chap.  xii. 

appeal's  in  the  stools,  together  with  small  shreds  of 
matter  that  on  examination  prove  to  be  gangrenous 
fragments  of  intestine.  The  elimination  may  be  pre- 
ceded by  absolute  constipation  and  by  severe  symptoms 
of  obstruction.  Or  it  may  be  preceded  by  a  profuse 
and  sudden  diarrhoea.  After  the  separation  is  com- 
plete there  is  usually  a  cessation  of  symptoms,  with 
the  exception  of  some  diaiThoea,  which  may  persist  for 
a  while. 

Finally  it  must  be  remembered  that  in  many 
patients  the  elimination  occurs  too  late  to  save  life 
and  the  sutferer  dies  of  the  effects  of  the  intussuscep- 
tion rather  than  from  any  e'sils  incident  to  its 
separation. 

One  point  remains.  On  page  199  a  case  has  been 
alluded  to  where,  as  a  result  of  limited  gangi^ene,  a 
rent  formed  in  the  inner  and  middle  layers  of  an 
invagination  tumour  whereby  the  intestinal  contents 
were  able  to  pass  between  the  intussusceptum  and  the 
intussuscipiens.  This  is  the  only  example  I  can  find 
of  what  may  possibly  proA*e  to  be  one  other  mode  of 
spontaneous  cure. 


CHAPTER    XII. 

STRICTURE    OF     THE    INTESTINE  :     PATHOLOGY. 

Under  the  general  term  "stricture  of  the  intestine" 
should  be  included  all  those  morbid  conditions  of  the 
boAvel  that  have  led  to  a  definite  narrowing  of  its 
lumen.  This  should,  perhaps,  more  particularly  hold 
good  in  any  account  of  intestinal  obstructions  wherein 
the  subject  was  approached  from  a  clinical  rather  than 
from  a  pathological  standpoint. 


Chap.  XII.]         Stricture:  Pathology.  253 

For  purposes  of  convenience,  however,  and  to 
avoid  bringing  together  under  one  heading  many 
perfectly  distinct  pathological  processes,  the  term 
"  stricture "  is  here  limited  to  a  narrowing  of  the 
lumen  brought  about  by  changes  in  the  coats  of  the 
bowel  itself.  These  changes,  it  should  be  further 
observed,  take  origin,  in  probably  every  instance,  in 
the  mucous  and  submucous  layers  of  the  gut,  for 
they  depend  upon  only  two  conditions,  upon  cicatrisa- 
tion after  loss  of  substance  and  upon  carcinomatous 
deposits.  Thus  from  the  present  category  are  excluded 
those  cases  of  stenosis  of  the  bowel  due  to  tlie  con- 
traction of  inflammatory  products  in  its  serous  coat, 
and  also  those  instances  of  narrowing  of  the  lumen 
of  the  bowel  from  kinking,  from  the  rigid  bending 
effected  by  adhesions,  from  the  matting  together  of 
sundry  coils,  and  from  the  shrinking  of  the  mesentery. 

Two  forms,  however,  of  genuine  stricture  of  the 
intestine,  as  expressed  by  the  above  definition,  have 
been  already  considered.  One  concerns  the  changes 
that  may  be  induced  in  the  walls  of  the  bowel  as  the 
result  of  long-continued  traction,  as  from  a  diverti- 
culum ;  the  other  concerns  the  constriction  that  may 
follow  after  the  sejoaration  of  an  intussusception. 

All  strictures  of  the  intestine,  as  limited  by  the 
definition  already  given,  may  be  divided  into  two 
gTeat  classes,  the  cicatricial  and  the  cancerous. 

1.    THE    CICATRICIAL    STEICTUEE. 

This  depends  upon  the  contracting  of  a  cicatrix  con- 
sequent upon  loss  of  substance  by  ulceration  or  limited 
gangrene  of  the  inner  coats.  The  aspect  and  degree  of 
the  stricture  will  obviously  depend  upon  the  situation 
and  extent  of  the  original  loss  of  substance.  A 
limited  patch  of  ulceration  placed  in  the  long  axis  of 
the  bowel  may  lead  to  very  insignificant  narrowing 
of  its  lumen,  while  an  ulcer  no  more  extensive  but 


2  54  Intestinal  Obstruction.       [Chap.  xii. 

disposed  transversely  around  the  gut  may  produce  an 
annular  constriction  that  may  almost  close  the  tube. 
Some  contracting  cicatrices  may  merely  alter  the 
course  or  direction  of  the  bowel,  others  that  are  not 
annular  may  pucker  up  a  portion  of  the  intestinal 
wall  and  produce  great  distortion  of  the  tube,  but 
without  much  narrowing  of  it.  An  evenly  dis- 
tributed scar  may  produce  a  regular  narro\^ing  of  the 
bowel,  while  an  unequally  contracting  cicatrix  may 
produce  obstruction  as  well  by  actually  diminishing 
the  size  of  the  canal  as  by  distorting  the  intestinal 
walls. 

It  will  be  readily  understood  that  the  cicatrix  that 
produces  the  greatest  amount  of  harm  with  the  least 
amount  of  contraction  is  that  that  assumes  an  annular 
form  ;  w^iile  the  least  harmful  cicatrix  is  the  one  that 
is  longitudinal  in  direction  and  that  involves  only 
a  part  of  the  circumference  of  the  bowel. 

It  is  convenient  to  divide  the  cicatricial  strictures 
into  three  classes.  1.  Those  depending  upon  primary 
ulceration.  2.  Those  that  are  subsequent  to  lesions 
following  strangulated  hernia.  3.  Those  that  may 
follow  injury.  The  first  class  concerns  both  the  large 
and  small  intestine.  The  others,  so  far  as  the  cases 
I  have  collected  serve  to  show,  concern  only  the 
lesser  bo^\'el. 

1.  Strietui'c  after  ulceration. — It  must  be 
confessed  that  our  knowledge  of  ulcerative  processes 
in  the  intestine  is  still  very  incomplete,  not  only  in 
their  pathology  but  also  in  their  clinical  bearings. 
Following  the  arrangement  of  Leube,*  intestinal 
ulcers  may  be  divided  into  six  classes.  1,  typhoid  ; 
2,  dysenteric  ;  3,  catarrhal ;  4,  peptic ;  5,  syphilitic  ; 
and  6,  tubercular. 

*Ziemssen's  Cyclopaedia  of  Medicine,  vol.  \'ii.,  page  399. 
See  aho  Die  Symptom,  der  Darmgeschwiire,  by  Nothnagel  in 
Volkmaun's  Sammlung,  No.  200,  1881. 


Chap. XII.]         Stricture:  Pathology.  255 

1.  Typlioid. — The  characters  of  these  ulcers  are 
well  known.  They  lead  to  distinct  and  recognisable 
scars,  but  it  is  only  in  extremely  rare  cases  that  they 
produce  any  stenosis  of  the  intestine.  This  is  not 
always  easy  to  understand.  It  is  true  that  the 
primary  typhoid  ulcer  is  often  of  no  great  extent,  is 
arranged  parallel  to  the  long  axis  of  the  bowel,  and 
involves  but  a  portion  of  its  circumference  ;  but  the 
serpiginous  ulcers  that  may  follow  upon  the  primary 
lesion  are  often  very  extensive,  involving  large  tracts 
of  the  intestine,  and  extending  so  deeply  as  to  pro- 
duce, in  a  few  instances,  perforation.  In  criticising  a 
case  of  reputed  stricture  after  typhoid  it  is  well  to 
remember  that  the  morbid  process  is  usually  limited 
to  the  ileum.  It  extends  to  the  colon  in  about  50 
per  cent,  of  the  cases,  but  even  then  very  rarely  indeed 
does  it  go  beyond  the  c?ecum  or  ascending  colon.  In 
the  other  direction  also  it  is  extremely  unusual  for 
the  disease  to  extend  higher  than  three  metres  from 
the  ileo-csecal  valve.*  Klob  gives  a  case  of  stenosis 
after  extensive  typhoid  ulcers.  I  have  not  been  able 
to  find  any  recorded  instance,  except  this,  that 
appears  to  be  an  midoubted  example  of  stricture  after 
enteric  fever.  Many  of  the  reputed  cases  do  not 
bear  examination,  and  the  association  of  a  f)revious 
typhoid  with  these  examples  is  probably  accidental.! 

2.  Dysenteric. — The  ulcers  left  by  dysentery 
are  frequent  causes  of  stricture.  These  ulcers  may 
be  met  with  in  the  rectum  alone  or  in  the  sigmoid 
flexure  or  in  the  CEecum  alone.  In  general  terms  it 
may  be  said  that  they  become  less  common  as  one 
passes  up  the  colon  from  the  rectum.  In  some 
instances  the  whole  of  the  large  intestine  has   been 

*  See  Hoffmann's  Statistics ;  Untersuch.  uber  die  path-anat. 
Verand.  der  Organe  beim  Abdominal  Typhus.     I^eipzig,  1869. 

^Seeiov  examples  case  by  Dr.  Bristowe ;  Path.  Soc.  Trans., 
vol.  iv.,  page  152.  Case  by  Dr.  Larguier  des  Bancels  ;  These 
de  Paris,  No.  142,  1870,  page  86. 


256  Intestinal  Obstruction.        [Chap,  xii. 

involved.  The  ulcers  iii  this  malady  are  often  very 
destructive.  They  have  a  tendency,  as  they  spread 
and  fuse,  to  isolate  little  patches  of  mucous  membrane, 
which  remain  undestroyed  and  stand  out  like  islands 
amonoj  the  ulcerated  districts.  As  the  scar  contracts 
these  islands  are  often  rendered  very  prominent,  and 
project  from  the  surface  as  hard  wartj'^-looking  excres- 
cences. The  cicatrix  is  often  extensive,  rigid,  and 
dense.  The  contraction  may  be  very  irregular.  The 
gut  may  be  much  puckered,  or  thrown  into  ii'regular 
folds  or  in  other  ways  distorted.  The  mucous  mem- 
brane often  becomes  undermined  durinsr  the  ulcerative 
process,  and  the  bands  of  membrane  thus  isolated 
commonly  remain  as  rigid  bars  and  cords  that  con- 
tribute one  more  element  to  the  irregular  aspect  of 
the  cicatrix.  Unilateral  scars  may  produce  a  bending 
of  the  gut  or  may  cause  sickle-like  folds  of  the 
intestinal  wall  to  project  into  the  lumen  of  the  tube. 
Such  folds  may  act  the  part  of  valves  and  increase 
the  obstruction,  and  the  same  may  sometimes  be  said 
of  the  elevations  and  excrescences  that  so  often  mark 
the  dysenteric  cicatrix.  An  example  of  stenosis  after 
dysentery  is  shown  in  Fig.  46.*  I  think  that  the 
nature  of  the  more  exuberant  of  the  cicatrices  has 
sometimes  been  unrecognised.  I  believe  that  not  a 
few  instances  of  so-called  "scirrhus"  of  the  colon  are 
examples  really  of  dense,  hard,  dysenteric  scars, 
associated  with  much  contraction  and  with  firm  warty 
excrescences.  It  is  not  improbable  that  one  of  the 
specimens  of  "  scirrhus  "  shown  m  the  St.  Thomas's 
Hospital  collection  f  is  really  an  example  of  extensive 
contraction  after  dysentery,  and  I  have  found  several 
museum  specimens  that  are,  T  think,  susceptible  of 
the  same  inter})retation.  Dysenteric  strictures  are 
most  often  met  with  in  the  rectum,  sigmoid  flexure, 

*  St.  Bart.'s  Hosp.  Museum,  No.  1,'J87.     See  also  No.  1,986. 
fSt.  Thomas's  Hosp.  Museum,  No.  Q  141. 


Chap.  XII  ] 


^57 


Fig.  46.— Stricture  of  Colon  after  dysenteric  Ulceration. 
E— 12 


258  Intestinal  Obstruction.        [Chap.  xii. 

and  descending  colon.     They  are  fairly  common,  also, 
at  both  the  hepatic  and  the  splenic  flexures. 

3.  Catarrhal. — These  ulcers  are  met  with  in  acute 
and  chronic  catarrh,  especially  in  the  latter.  They 
usually  begin  as  erosions,  and  in  the  small  intestine 
often  follow  for  a  while  the  edges  of  the  valvular 
coniventes.  They  may  spread  in  a  serpiginous  manner 
and  so  isolate  patches  of  healthy  mucous  membrane. 
In  another  form  described  by  Leube  the  mischief 
commences  in  the  lymphoid  follicles,  the  tissue  of  which 
inflames  and,  breaking  down,  forms  a  follicular  ulcer. 

Catarrhal  ulcers  are  most  commonly  limited  to  the 
colon. 

With  them  must  also  be  included  the  so-called 
stercoral  ulcers  due  to  the  mechanical  and  chemical 
irritation  of  arrested  fsecal  masses.  These  ulcers  are 
often  met  with  in  the  colon  in  chronic  constipation, 
and  in  the  bowel  above  an  obstruction  in  the  large 
intestine.  They  most  frequently  occur  in  the  caecum 
and  next  in  fiequency  at  the  flexures  of  the  colon. 
They  may  lead  to  perforation  and  are  no  doubt  often 
the  starting  point  of  stenosis.  They  are  usually 
multiple,  are  oval  and  parallel  to  one  another,  follow 
the  transverse  folds  of  the  bowel,  and  are  thus  at  right 
angles  to  its  long  axis."^ 

4.  Peptic.^This  ulcer  is  met  with  at  the  com- 
mencement of  the  duodenum,  and  is  said  to  be  pro- 
duced by  the  digestive  action  of  the  gastric  juice.  It 
is  usually  single,  is  most  common  between  the  ages  of 
thirty  and  forty,  and  is  more  frequent  in  males  than 
in  females  in  the  proportion  of  ten  to  one.  It  may 
yjerf orate,  and,  according  to  both  Leichtenstern  and 
Leube,  may  lead  to  stenosis. 

5.  Sypliilitir  ulcers  of  the  bowel  are  said  to  be 
most  often  due  to  the  breaking  down  of  gummata  in 

■••  SV.  inijiaiiccfj  by  Dr.  Dicldiisou  ;  I'ath  Soc.  Trans.,  vol.  xviii., 
page  101. 


Chap.  XII.]         Stricture  :  Pathology,  259 

the  submucous  tissue.  The  ulcers  thus  formed  may 
iTin  round  the  gut  in  an  annular  manner,  or  may 
form  isolated  ulcers  with  a  rounded  or  serpiginous 
outline  having  a  remarkably  uneven  surface  and 
■well  cut  and  slightly  undermined  edges. 

Excluding  the  rectum,  this  form  of  ulcer  is  said  to 
be  most  common  in  the  lower  ileum. 

6.  Tubercular.— These  ulcers  begin  in  the  lym- 
phoid follicles  and  assume  a  course  and  appearance 
A'ery  much  like  that  observed  in  scrofulous  ulceration 
of  the  pharynx.  They  increase  by  spreading  at  the 
edge  and  generally  ado})t  a  transverse  dii^ection  fol- 
lowing the  course  of  the  vessels  around  the  gut.  They 
often  thus  extend  around  the  whole  circumference  of 
the  bowel.  In  other  instances  the  ulcer  is  oval  and 
elongated  with  its  long  axis  in  the  long  axis  of  the 
intestine.  Some,  again,  are  rounded  and  others  sinuous. 
The  edges  of  the  sore  may  be  thin,  irregular,  and 
undermined,  as  if  the  mucous  membrane  had  rotted  off 
in  patches.  In  other  and  probably  more  advanced 
cases  the  margin  becomes  defined,  thickened,  and 
rounded. 

These  ulcers  may  be  met  with  in  almost  any  part  of 
the  intestine,  and  often  involve  a  great  extent  of  the 
bowel.  They  are  most  common,  however,  in  the 
lower  ileum  and  about  the  ileo-caecal  valve.  When 
associated  with  marked  tuberculous  deposits  and  with 
tuberculosis  elsewhere  they  seldom  heal.  The  milder 
cases,  however,  cicatrise,  and  then  the  annular  ulcers 
may  produce  some  stenosis  of  the  intestine.  This 
stenosis  is,  T  think,  usually  of  a  moderate  degree.  A 
specimen  of  stricture  from  tubercular  ulcer  is  shown 
in  Fig.  47. 

Returning  to  the  intestine  and  examining  the 
simple  strictures  of  that  tube  that  may  be  ascribed  to 
cicatrisation  after  ulcer,  one  is  impressed  with  the 
comparative  valuelessness  of  the  classification  of  ulcers 


260 


Intestinal  Obstruction.        [Chap.  xii, 

just  given.  In  some 
instances  there  is  no 
doubt  that  the  stric- 
ture has  followed  a 
dysenteric  or  a  tuber- 
cular ulcer,  or  there 
are  good  reasons  for 
supposing  that  it  has 
been  due  to  a  catar- 
rhal ulcer,  but  cer- 
tainly in  the  majority 
of  the  cases  the  con- 
clusion as  to  the 
origin  of  the  stricture 
is  purely  negative.  It 
may  be  evident  that 
it  is  not  due  to  ty- 
phoid or  to  dysentery, 
or  to  tuberculosis, 
but  beyond  that  the 
diagnosis,  in  a  vast 
number  of  cases,  does 
not  and  cannot  go. 

Regarding  these 
strictures  collectively 
it  may  be  said  that 
they  are  usually  defi- 
nite and  well  limited. 
As  viewed  from  the 
peritoneal  surface 
they  may  appear 
merely  as  a  well- 
marked  constriction  of 

Fig.47.— Portion  of  Jejimum 
showing  two  Strictures, 
the  result  of  tubercular 
Ulceration. 

The  put  has  Ixen  turned  inside 
out  so  as  to  show  the  luucoiis 
surface. 


Chap. XTi.i         Stricture :  Pathology.  261 

the  gilt,  as  if  a  cord  or  tape  Iiad  been  tied  about  it,  or 
may  have  induced  more  distortion  of  the  bo\yel.  The 
former  condition  is  perhaps  more  often  met  witli  in 
the  large  intestine  and  the  latter  in  the  small.  In  the 
lesser  bowel  the  strictured  part  is  usually  free  and 
exempt  from  adhesions  to  adjacent  surfaces.  In  the 
colon,  however,  the  stenosed  segment  is  often  bound 
down,  especially  when  the  part  involved  is  one  or 
other  of  the  flexures.  The  lumen  of  the  narrowed 
tube  may  be  regular  in  outline  or  much  distorted. 

It  may  at  the  time  of  its  causing  death  admit  the 
forefinger,  or  l^e,  on  the  other  hand,  so  small  as  to 
hardly  permit  the  introduction  of  a  probe. 

As  regards  locality,  strictures  of  the  lesser  bowel  are 
usually  situated  in  the  ileum  and  preferably  in  the 
middle  or  lower  parts  of  the  ileum.  In  the  colon  about  50 
per  cent,  of  these  cicatricial  strictures  are  in  the  sigmoid 
flexure.  Next  in  frequency  come  the  descending  colon 
and  splenic  flexure,  and  beyond  those  parts  the  stenoses 
become  rarer  and  rarer  as  the  ciTecum  is  approached. 

In  comparing  the  large  intestine  with  the  small, 
one  is  struck  with  the  fact  that  the  simple  stricture  of 
the  colon  is  nearly  always  single.  Indeed,  out  of 
thirteen  recorded  cases  that  I  have  collected  there  is 
only  one  example  of  multiple  simple  stricture  of  the 
large  intestine.  In  this  instance  the  patient,  a  woman 
aged  twenty-nine,  had,  in  addition  to  a  stricture  of  the 
rectum,  a  stricture  at  the  hepatic  and  at  tbe  splenic 
flexures."^  On  the  other  hand,  out  of  ten  recorded 
cases  of  cicatricial  stricture  of  the  lesser  bowel  there 
were  six  instances  of  single  stricture  and  four  of 
multiple.  In  one  of  the  six  cases  there  were  cica- 
trices in  the  gullet  and  stomach  in  addition  to  that 
producing  stenosis  of  t\\Q  intestine,  f     The  four  cases 

*  M.  Marignac  ;  Bull,  de  la  Soc.  Anat.,  1877,  page  519. 
f  Dr.  Bristowe  ;  Path.  Soc.  Trans.,  vol.  xx.,  page  180.     The 
nature  of  the  cicatrices  was  unknown. 


262  Intestinal  Obstruction.        LChap.  xii. 

(-L  iniiltiple  stricture  present  certain  very  striking 
characters  that  are  common  to  the  series.  The 
patients  were  all  women  except  one.  They  were  all 
young  adults,  their  ages  ranging  from  twenty-two  to 
thirty-three.  There  were  three  or  four  definite 
strictures  in  each  case,  which  were  placed  at  varying 
distances  apart.  The  ileum  was  involved  in  each 
instance.  In  none  of  the  cases  was  the  nature  of  the 
ulceration  upon  which  the  cicatrisation  depended 
diagnosed.* 

There  is  no  doubt  but  that  the  present  variety  of 
cicatricial  stricture  is  very  much  more  common  in  the 
large  than  in  the  small  intestine.  The  statistics,  how- 
ever, at  present  available  are  not  sufficiently  exten- 
sive to  form  the  basis  for  a  correct  estimation  of  the 
comparative  frequency. 

My  own  statistics  are,  I  am  aware,  misleading, 
and  if  one  could  j  udge  roughly  from  a  general  exami- 
nation of  museum  specimens,  it  may  be  said  that  the 
proportion  in  which  the  large  and  small  gut  is  involved 
is  about  as  six  to  one. 

I  have  met  with  five  recorded  instances  of  stenosis 
of  the  ileo-ctecal  vah'e  subsequent  to  the  cicatrisation 
of  ulcers.  In  one  of  the  cases  the  ulcers  appeared  to 
have  spread  from  the  ileum,  and  in  another  example 
from  the  colon.  In  the  remaining  instances  the  sten- 
osis had  probably  followed  a  typhlitis  brought  about 
by  the  impaction   of  freces  or  masses   of    undigested 

*  As  a  good  example  of  the  series,  sec  Koeberle's  famous  case, 
in  which  he  resected  with  success  tv^'o  metres  of  ileum ;  Bull,  et 
M^m.  de  la  Soc.  de  Chir.  de  Paris,  1881,  page  99.  [See  also  St. 
Thomas's  Hosp.  Museum,  No.  Q 127  and  No.  Q  129.)  Since  the  above 
was  written  a  fifth  case  lias  been  added  to  this  series  in  the  form  of 
a  very  interesting  specimen  exhibited  by  Dr.  Sharkey  before  the 
Pathological  Society  {Lancet,  ISIay  24,  1884).  Here  there  were 
multiple  strictures,  due  obviously  to  the  cicatrisation  of  ulcers. 
The  patient  was  a  woman,  aged  twenty-three.  The  iiart  of  gut 
involved  was  the  ileum,  and  the  nature  of  the  ulceration  was  not 
esta)>lished,  althougli  the  specimen  had  been  the  subject  of  most 
careful  examination. 


Chap.  XII.]  Stricture  :  Fa  thology.  263 

food  in  the  cKcum.  In  two  of  tlio  cases  the  valve 
just  admitted  the  point  of  tlie  finger,  in  another  it 
would  only  give  passage  to  a  No.  9  catheter,'^  and 
in  a  fourth  case  it  was  almost  entirely  obliterated.! 
Tn  this  last  instance  the  ileum  and  csecum  communi- 
cated by  means  of  a  fistulous  opening,  and  the  closure 
of  the  valve  proved  a  matter  of  comparatively  little 
importance. 

An  excellent  example  of  stricture  of  the  ileo-caecal 
valve  is  shown  in  Fio*  48.  In  this  case  the  stenosis 
was  due  to  cicatrisation  after  ulcer,  t 

2.  Stricture  after  strangulated  hernia.— 
The  stricture  that  may  form  in  a  piece  of  the  intestine 
that  has  been  involved  in  a  stranguliited  hernia  is  due 
to  cicatrisation  and  follows  upon  ulceration  or  limited 
gangrene  of  the  involved  bowel.  I  have  found  four 
recorded  examples  of  this  stricture,  in  addition  to 
several  specimens  to  be  seen  in  some  of  the  London 
museums.  It  has  followed  upon  both  inguinal  and 
femoral  rupture,  and  has  produced  symptoms  of  ob- 
struction at  a  period,  after  the  relief  of  the  hernia  by 
operation,  varying  from  one  month  to  "  some  years." 
In  three  cases  the  ileum  was  involved ;  in  one  the 
jejunum.  In  one  instance  one  and  a  half  inches  of 
the  bowel  were  found  contracted  and  thickened.  §  In 
other  examples  the  stricture  was  of  very  limited  ex- 
tent and  amiular  as  if  a  narrow  tape  had  encircled  the 
bowel.  In  one  example  the  stenosed  part  would  only 
admit  a  goose-quill,  ||  and  in  another  water  would  only 
pass  through  it  in  drops. IT    In  one  specimen"^"^  a  large 

*  Path.  Soc.  Trans.,  vol.  xxi.,  iiage  171. 

t  Berlin,  kliu.  "Wochens,  Xo.  26,  i)age  393,  June,  1879. 

X  For  examples  ^€e.  Coll.  of  Sm-geons  Museum,  Nos.  1,247  and 
1,248. 

^  Med.  Times  and  Gazette,  vol.  i.,  1872,  page  3G3. 

II  Bull,  et  Mem.  de  la  Soc.  de  Cliir.  de  Paris,  1880,  page  706. 

11  Path.  Soc.  Trans.,  vol.  iii.,  page  05. 

**  MidtUesex  Ho.sp.  Museum,  Xo.  114,  \-iii.  ;  see  also  Guy's 
Ho>ipital  IMuseum,  Xo.  2,o07  [30). 


264 


Intestinal  Obstruction.       [cimp.  xii. 


a 

Fig.  48.— Strictnro  of  the  Tleo-ccecal  "Valve. 
n,  cnerum  not  laid  opon  ;  h,  ileum  Inid  oi.cn  ;  c,  ricatricos  of  ulcers;  rf,  piirkered 
iiiucousnionihrane.     The  vulvf,  winch  wns  rcduct'd  to  the  size  of  a  No.  12 
catheter,  Is  occuviei!  by  a  piece  of  whalebone. 


Chap,  xii.]         Stricture:  Pathology.  265 

valvular  fold  of  mucous  meml irane  passed  across  the 
lumen  of  the  gut  at  the  strictuved  part. 

3.  Stricture  after  injiiiy.— I  find  records  of  two 
cases  of  stricture  that  were  evidently  due  to  cicatrisa- 
tion following  injury  to  the  howel.  Both  patients 
were  males  aged  about  forty-five.  In  one  case  symp- 
toms of  obstruction  came  on  three  montlis  after  the 
patient  had  been  ridden  over,"^  in  the  other  case  four 
months  after  a  blow  upon  the  abdomen,  f  In  the  for- 
mer the  ileum  was  involved,  in  the  latter  the  upper 
jejunum.  Both  strictures  were  very  narrow,  and 
adhesions  existed  in  the  vicinity  of  the  stenosed  seg- 
ments. 

In  the  Pathological  Society's  Transactions  %  Mr, 
Ward  details  a  case  where  the  lower  three  inches  oi 
the  ileum  were  found  much  contracted  and  thickened, 
the  ileo-csecal  valve  "  a  mere  ridge,"  and  the  caecum 
somewhat  narrowed.  Some  large  gall-stones,  much 
worn,  were  found  in  the  caecum,  and  it  may  be  that 
the  trouble  in  the  ileum  was  induced  by  their  tem- 
porary impaction  there. 

I  have  not  entered  into  the  subject  of  congenital 
strictures  of  the  intestine. 

It  may  here  be  convenient  to  draw  attention  to  a 
specimen  in  the  Museum  of  University  College  Hos 
pital,  which  is,  so  far  as  I  can  ascertain,  quite  unique. 

A  drawing  of  the  specimen  is  shown  in  Fig.  49. 

It  shows  a  portion  of  the  small  intestine,  the  lumen 
of  which  has  been  at  one  point  remarkably  narrowed. 
The  narrowing  is  due  to  an  even  folding-in  of  all  the 
coats  of  the  bowel  towards  the  lumen  of  the  tube. 

This  infolding  involves  only  a  portion  of  the  cir- 
cumference of  the  intestine.  The  infolded  parts 
appear   quite   normal   on   section,   save   for   a   little 

*  Path.  Soc.  Trans.,  vol.  iv.,  page  loG. 
t  Bull,  de  la  Soc.  Anat. ,  1877,  page  86, 
X  Vol.  for  1858,  page  365. 


266 


Intes  tjna  l  Obs  tr  uction. 


[Chap.  XII. 


thickening  of  the  mucous  membrane.  The  fold  is 
rendered  permanent  by  adhesions  between  tlie  two 
opposed  serous  surfaces.  The  infolding  is  towards  the 
mesenteric  attachment  of  the  ])owel.  In  the  mesen- 
•tery  are  certain  enlarged  and  inflamed  glands  in  close 
contact  with  the  gut.  The  specimen  was  obtained  from 
the  body  of  a  man  who  died  of  intestinal  obstruction. 


Fig-.  49.— stenosis  due  to  iu-turnmEr  of  the  Intestinal  Wall,  the  result  of 
Mesenteric  Gland  Disease. 

Of  the  nature  of  the  obstruction  in  this  case  it  is 
difficult  to  speak.  It  is  certainly  not  a  stricture  in 
the  proper  sense.  It  may  be  a  case  of  abrupt  bending 
of  the  intestine  with  fusion  of  the  oj^posed  surfaces  at 
tlie  angle  of  the  l)end.  Cases  of  this  character  have 
been  already  dealt  with,  but  they  do  not  present  the 
peculiarities  afforded  by  the  i)resent  specimen.      The 


Chap. XII.]         Stricture:  Pathology.  267 

gut,  moreover,  if  viewed  laterally  does  not  present 
evidences  of  acute  bending.  It  can  only  be  surmised 
that  the  condition  is  associated  with  the  mesenteric 
gland  disease,  and  that  the  little  local  peritonitis  ex- 
cited had  spread  from  the  disordered  lymph  glands. 
Above  the  stenosed  part  is  a  considerable  pouch. 

2.    THE    CANCEROUS    STRICTURE. 

Carcinoma  of  the  intestine  may  be  either  primary 
or  secondary.  As  a  secondary  growth  it  may  appear 
either  by  metastasis  or  by  extension  from  neighbour- 
ing parts.  So  far  as  surgical  practice  is  concerned, 
the  growth  causing  obstruction  or  definite  intestinal 
symptoms  is  usually  primary ;  and  the  metastatic 
form  need  not  be  considered  here."^ 

It  must  be  confessed  that  the  pathology  of  cancer 
of  the  intestine  is  by  no  means  in  a  satisfactory  con- 
dition, and  there  is  a  great  lack  among  available 
records  of  full  and  detailed  accounts  of  the  micro- 
scopical structure  of  these  growths.  According  to 
most  authors,  primary  carcinoma  of  the  bowel  includes 
the  following  varieties,  viz.  scirrhus,  medullary, 
colloid,  and  epithelial.  With  regard  to  scirrhus,  I  have 
not  been  able  to  find  any  clear  description  of  an  un- 
doubted primary  scirrhus  growth  in  the  intestine,  nor 
have  I  been  able  to  find  in  the  various  museums  any 
specimens  of  this  condition  that  are  beyond  question. 
I  am  much,  disposed  to  doubt  its  existence.  Mr. 
Harrison  Cripps,  as  the  result  of  his  extensive  investi- 
gations into  new  growths  of  the  rectum,  doubts  the  ex- 
istence of  scirrhus  or  medullary  cancer  in  that  part, 
and  has  been  unal:>le  to  find  any  examples  of  such 
growths  in  that  segment  of  the  bowel. 

*  Mr.  R.  Williams,  in  a  statistical  paper  dealing  with  5,556 
cases  of  carcinoma  of  all  parts,  has  collected  forty-nine  instances  of 
cancer  of  the  intestine,  twenty-three  being  in  male,  and  twenty-six 
in  female  subjects  [Lancet,  May,  24,  1884). 


268  Intestinal  Obstruction.       [Chap.  xii. 

Tlie  same  remark  that  applies  to  scirrlius  applies 
also  to  medullary  carcinoma.  I  can  find  no  record  of 
any  case  of  primary  cancer  of  the  bowel  that  upon 
microscopical  examination  was  proved  to  have  been 
without  doubt  an  encephaloid  growth. 

Putting  aside  for  a  moment  the  subject  of  colloid 
cancer,  one  is  now  driven  to  the  conclusion  that  the 
most  usual  form  of  carcinoma  of  the  intestine  is  cylin- 
drical eiDithelioma.  ]Mr.  Harrison  Cripps  has  very 
clearly  shown  that  the  usual  "  malignant  disease  "  of 
the  rectum  is  of  this  character,  and  the  rectum  is  not 
so  entirely  unlike  the  rest  of  the  intestinal  tube  as  to 
lead  ns  to  anticipate  that  it  possesses  a  peculiar  mono- 
poly in  its  morbid  growths.  In  an  admirable  mono- 
graph upon  cancer  of  the  int/Cstine  recently  published 
by  M.  Haussmann,  the  conclusion  above  expressed  re- 
ceives very  substantial  confirmation."^  M.  Hauss- 
mann has  collected  no  less  than  268  recorded  cases  of 
so-called  cancer  of  the  intestine. 

In  seventy-three  of  these  cases  a  microscopical  ex- 
amination of  the  growth  is  given,  with  the  result  that 
in  forty-three  instances  the  neoplasm  proved  to  be  a 
cylindrical  epithelioma.  In  four  of  the  remaining 
thirty  cases  the  mass  is  described  as  colloid  and  might 
have  been  an  epithelioma  that  had  undergone  the  col- 
loid change.  With  regard  to  the  rest  of  the  cases,  it  is 
significant  that  they  mainly  belong  to  the  older  de- 
scriptions and  to  a  period  antecedent  to  the  time  of  an 
elaborate  pathological  histology.  M.  Haussmann's 
observations  upon  these  statistics,  and  his  general  con- 
clusion upon  the  whole  subject,  are  expressed  in  tho 
following  words  :  "  Examinons  en  effet  les  dates  de 
nos  observations    et    nous   pourrons  facilement  nous 

*  Cancer  de  I'lntestin.  These  de  Paris,  1882,  No.  228.  I 
might  be  allowed  to  say  that  I  had  funned  the  conclusion  above 
named  many  months  before  I  had  read  ^I.  Haussmann's  mono- 
grai»h. 


Chap. XII.]        Stricture:  Pathology.  269 

convaincre  de  Texistence  crun  fait  important  :  lo  car- 
cinome  intestinal  devient  de  plus  en  plus  rare  a  mesure 
que  Ton  s'approche  davantage  de  I'epoque  actuelle. 
Si  nous  ne  tenons  compte  de  cliaque  cote  que  des  faits 
observes  depuis  1875,  nous  voyons  le  nombre  des  car- 
cinomes  descendre  a  8,  tandis  que  celui  des  epitheliomes 
se  maintient  a  26.  Si  nous  rapprochons  encore  notre 
point  de  depart  et  si  de  1875  nous  le  reportons  a  1879, 
c'est  3  carcinomes  seulement  que  nous  voyons  rester 
debout  en  face  de  24  epitheliomas  cylindriques.  II 
nous  semble  que  cette  marche  si  rapidement  decrois- 
sante  du  carcinome  demontre  suffisamment  sans  meme 
que  Ton  entre  dans  I'examen  des  faits,  que  le  car- 
cinome de  I'intestine  est  destine  a  disparaitre.  Nou.s 
croyons  done  pouvoir  legitimement  conclure  de  cetto 
discussion  que  tous  les  varietes  de  cancer  de  I'intestin 
admises  jusqu'  a  present  doivent  etre  ramenees  a  une 
seule  :  I'epithelioma  cylindrique.  Nous  domierons  done 
du  cancer  de  I'intestin  la  definition  suivante :  le  cancer  de 
I'intestin  est  I'epitlielioma  cylindrique  de  cet  organe." 
"With  regard  to  colloid  cancer  one  cannot  but  be 
struck  with  the  fact  that  this  form  of  carcinoma  is 
not  so  commonly  met  with  as  it  was.  An  examina- 
tion of  the  "Transactions  of  the  Pathological  Society" 
from  their  first  volume  to  the  present  time  would 
induce  the  belief  that  this  form  of  neoplasm  is 
becoming  extinct.  In  other  words,  a  more  precise 
and  advanced  pathology  would  appear  to  be  rapidly 
narrowing  the  extensive  ground  it  once  covered. 
Colloid  carcinoma  is  usually  defined  as  a  schirrus, 
medullary,  or  epithelial  cancer,  the  cells  of  which  have 
undergone  colloid  degeneration.  Some  of  the  re- 
ported cases  of  colloid  cancer  may  have  been  incor- 
rectly associated  with  that  name,  others  might  have 
been  examples  of  the  colloid  degeneration  of  secondary 
growths,  while  not  a  few  were  probably  instances  of 
colloid  change  in  a  j^rimary  epitheliomatous  growth. 


270  Intestinal  Obstruction,        [cuap.  xii. 

An  exaniinatioii  of  all  tlie  so-called  specimens  of 
"intestinal  cancer"  to  be  found  in  museums,  etc., 
will  show  that  they  can  be  readily  divided  into  two 
great  classes  ;  into  examples  of  cylindiical  epithelioma 
and  into  instances  of  neoplasms  that  do  not  belong  to 
the  epitheliomata.  One  class  is  positive,  the  other,  so 
far  as  pathological  knowledge  at  present  extends,  is 
negative. 

We  may  consider  first  the  growths  alluded  to  as 
forming  the  second  class  in  this  division,  a  division 
that  simply  has  for  its  object  the  separation  of  the 
well-defined  epitheliomata  from  the  other  and  some- 
what ambiguous  growths  that  are  classed  together  as 
^'cancers "of  the  intestine.  There  is  no  reason  for 
supposing  that  these  neoplasms  are  all  of  the  same 
character,  although  when  viewed  collectively  they  pre- 
sent certain  general  features  which  may  be  expressed 
in  the  following  description.  They  appear  first  as 
rounded  nodules  under  the  mucous  membrane  and  are 
covered  by  a  healthy  layer  of  that  tunic.  These  nodu- 
les may  be  single,  but  they  are  nearly  always  multiple. 
They  may  be  met  with  here  and  there  at  many  different 
points  in  the  intestine  more  or  less  remote  from  one 
another,  or  many  may  be  found  clustered  together  in 
a  comparatively  small  segment  of  the  bowel.  (aS'^^ 
Fig.  50.*)  They  usually  form  very  distinct  and  j)romi- 
nent  projections,  varying  in  size  from  a  pea  to  a  large 
nu  rble. 

These  isolated  new  growths,  Mhich  are  at  first 
separated  and  surrounded  by  healthy  mucous  mem- 
brane, increase  in  size,  and  it  is  possible  that  those 
that  are  in  near  relation  to  one  another  may  coalesce. 
By  one  means  or  by  another  the  morbid  growth  forms 
a  mass  of  some  magnitude,  then  the  mucous  mem- 
brane that  covers  it  breaks  down  and  the  surface  of 

*  St.  Bait.'s  Hosi).  Museum,  No.  2,020.  /b'ce  uUo  Coll.  of 
Surgeons  IMuscuiu,  No.  1,220. 


Oiap.  XII.] 


Stricture  :  Pathology. 


27T 


the  tumour  becomes  excavated  by  an  ulcerative  pro- 
cess. It  would  appear  that  the  neoplasm  may  disin- 
tegrate almost  as  rapidly  as  it  grows,  and  so  indefi- 
nitely postpone  the  serious  narrowing  of  the  lumen 
of  the  bowel  that  a])pears  always  imminent.  The  new 
growth  spreads  in  depth  as  well  as  superficially.  It 
would  seem  to   take   its  origin   from  the  submucous 


Fig.  50.—  Cauoer  of  jojuuuni. 

tissue,  but  soon  invades  all  the  coats  of  the  intestine. 
It  commonly  assumes  an  annular  form,  and,  folloM'ing 
the  direction  of  the  blood-vessels,  is  soon  found  to  lla^■e 
encircled  the  intestine.  In  other  instances  it  remains 
as  a  large  flattened  tumour,  that  has  ajjparently  spread 
equally  in  all  directions,  that  may  extend  around 
three -fourths  of  the  lumen  of  the  intestine,  and 
that    will    present    an   ulcerated    and    broken-down 


272  Intestinal  Obstruction.        (chap.  xil. 

surface.*  New  growths  such  as  these  are  variously  de- 
scribed as  "cancer,"  "colloid  cancer,"  "villous  cancer," 
and  "  medullary  cancer."  They  are  commonly  attended 
by  like  enlargements  in  the  mesenteric]  glands,  and  in 
advanced  cases  by  miliary  nodules  in  the  serous  mem- 
brane. As  regards  the  nature  of  these  growths  I  am 
inclined  to  think  that  the  great  majority  of  them  are 
examples  of  secondary  deposits,  although  they  may 
not  be  so  described  in  museum  catalogues.  They  pre- 
cisely resemble,  both  in  appearance  and  in  general 
arrangement,  new  gi'owths  in  the  intestine  that  are 
avowedly  secondary  to  tumours  elsewhere.  The  mul- 
tiplicity of  the  deposits,  and  the  frequent  extensive 
implication  of  the  serous  membrane,  are  features  that 
Avould  suggest  secondary  rather  than  primary  growths. 

It  is,  moreover,  to  be  noted  that  this  is  not  the 
form  of  cai'cinoma  usually  met  with  in  surgic^d  prac- 
tice, not  the  form  that  is  apt  to  assume  a  somewhat 
lingering  course  and  to  produce  a  certain  and  pro- 
gressive narrowing  of  the  intestine,  and  not  the  form 
that  is  usually  met  with  in  the  clinical  records  of 
those  who  have  died  Avitli  distinct  symptoms  of 
stricture  of  the  bowel.  Some  present  all  the  aspects 
displayed  by  specimens  of  lympho-sarcoma  of  the 
bowel,  the  nature  of  which  has  been  placed  beyond 
doubt. 

From  this  somewhat  vague  and  probably  hetero- 
geneous collection  of  new  growths  we  might  turn  to  the 
well-defined  exami)les  of  carcinoma  that  form  the  first 
of  the  two  classes  above  alluded  to,  the  cylindrical 
epitheliomata. 

Cylindromata  may  l)e  met  with  in  the  bowel  under 
three  different  aspects:  (1)  As  small  nodules;  (2) 
as  flattened  plaques  involving  only  a  portion  of  the 

*  For  specimens  .see  Middlesex  Hosj).  Museum,  No.  viii.  113a  ; 
Coll.  of  Surgeons  Museum,  No.  1,221 ;  Guy's  Hosp.  IMuseum, 
No  1,881  (97) ;  and  Lond.  Hosp.  Muaeum,  No.  Af.  28. 


Chop,  xn.]         Stricture :  Pathology.  273 

circumference  of  the  gut ;  and  (3)  as  annular  deposits 
wliich  surround  the  bowel  like  a  ring.  Into  the 
microscopic  characters  of  this  form  of  epithelioma  it 
is  not  necessary  to  enter.  The  morljid  changes  com- 
mence in  the  epithelium  of  Lieberkiihn's  glands,  and 
produce  at  first  a  great  thickening  of  the  glandular 
layer  of  the  mucous  membrane  for  some  distance,  or 
the  neoplastic  action  may  be  more  limited  to  one  spot 
and  a  projecting  nodule  be  produced.  Some  of  these 
nodules  form  conspicuous  tumours  which  are  very  apt 
to  assume  a  polypoid  outline.  In  other  instances  the 
growth  sjjreads  laterally  rather  than  towards  the 
lumen  of  the  bowel,  and  an  epitheliomatous  plaque  is 
produced.  In  this  form  a  raised  flattened  mass  of 
neoplastic  structure  is  formed  upon  one  part  of  the 
intestinal  wall.  Its  edges  are  well  defined  and  often 
abruptly  raised,  its  centre  is  uneven  and  often  ulce- 
rated. An  example  of  the  nodular  or  polypoid  form 
is  afforded  by  Fig.  51.^ 

The  commonest  form,  however,  under  which  epithe- 
lioma of  the  intestine  presents  itself  is  that  of  an  annular 
band  around  the  intestine.  Compared  with  this  asjoect 
of  the  growth  the  nodules  and  plaques  may  be  said  to  be 
comparatively  rare.  The  ring-like  formation  affords 
an  example  of  the  neoplasm  directed  in  its  course  by 
the  blood-vessels  of  the  part,  which  here  follow  a 
course  transversely  to  the  long  axis  of  the  bowel.  It 
is  this  form  of  epithelioma  that  usually  is  met  with 
under  the  title  of  malignant  stricture  of  the  intestine, 
and  it  probably  represents  the  only  true  cancerous 
stricture  of  this  part.  The  appearance  of  these  stric- 
tures is  very  typical.  The  gut  at  the  stenosed  part 
appears  to  be  very  suddenly  constricted,  as  if  a  piece 
of  cord  had  been  drawn  tightly  about  it.  The  stricture 
is  usually  quite  annular  but  insignificant  in  width, 

*  Coll.  of  Surgeons  Museum,  No.  1,222.  See  also  Path.  Soc. 
Trans.,  vol.  iv.,  page  1.54;  and  St.  Bart.'sHosp.  Musemn,  No.  2,023, 

s— 12 


274 


tChap.  XII. 


Fig.  51.— Epithelioma  of  Colon. 
a,  tumour;  b.  Bite  of  lumen  of  bowel ;  r,  appendices  epiiiloicae. 


Chap.  XII.]         Stricture:  Pathology.  275 

comparatively  little  of  the  gut,  as  measured  along  its 
long  axis,  being  involved.  The  peritoneum  about 
the  stenosed  part  is  often  thickened  and  the  bowel 
itself  is  not  infrequently  adherent.  On  examining 
the  gut  from  the  inside  the  stricture  may  appear  as 
an  annular  and  contracted  deposit,  the  surface  of 
which  is  irregularly  ulcerated.  Sometimes  the  stric- 
ture appears  as  if  contracted  about  one  of  the  nodular 
growths  already  described.  In  other  instances  the 
neoplasm  has  extended  laterally  more  after  the  manner 
of  a  plaque,  and  the  edge  of  the  new  growth,  or  rather 
of  the  ulcerated  surface  that  it  has  left^  shows  a  dis- 
tinct rounded,  raised,  and  everted  border  which  is 
very  typical  and  very  pronounced.  This  is  Avell 
shown  in  the  specimen  from  which  Fig.  52"^  has  Vjeen 
taken.  Strictures  of  this  character  are  often  very 
narrow.  Some,  for  example,  in  the  colon  have  been 
decided  as  "almost  closed,"  or  as  allowing  only  a 
probe  to  pass,  or  as  having  a  diameter  no  greater  than 
that  of  a  goose-quill.  They  are  much  more  common 
in  the  large  than  in  the  small  intestine,  and  I  have  met 
with  several  specimens  where  the  margins  of  the  ileo- 
csecal  valve  were  the  seat  of  an  epitheliomatous  growth. 

It  is  important  to  recognise  the  fact  that  epithe- 
liomata  of  the  intestine  appear  as  single  growths.  I 
have  not  been  able  to  find  any  undoubted  example  of 
multiple  primary  epithelioma.  In  this  respect,  there- 
fore, it  differs  markedly  from  the  other  forms  of 
so-called  cancer.  The  mesenteric  glands  were  found 
involved  in  about  50  per  cent,  of  the  recorded  cases, 
but  this  complication  is,  without  doubt,  late  to  appear. 

Of  the  causes  that  produce  these  growths  nothing 

is  known.     In  one  interesting  case  mentioned  by  M. 

Isenard  a  well-marked  cylindrical  epithelioma  appears 

to  have  developed  upon  the  scar  left  by  a  dysenteric 

*  St.  Bart. '3  Hosp.  Museum,  No.  2,020.    See  also  Coll.  of  Sur- 
geons Museum,  No.  1,223. 


276 


Intestinal  Obstruction,        rchap.  xii. 


ulcer.  The  patient  had  had  dysentery  two  years  pre- 
viously, and  in  the  vicinity  of  the  carcinoma  were 
many  dysenteric  cicatrices."* 

In  addition  to  the  forms  of  carcinoma  here  dealt 
with  it  is  necessary  to  bear  in  mind  that  besides  the 
primary  and  the  metastatic  varieties  of  cancer  of  the 
bowel  there  are  cases  in  which  a  cancerous  growth  has 


Fig.  52.— Epithelioma  of  Colon.     Bird's-eye  view  of  the  Interior  of  the 

Bowel. 
At  a,  a  triangular  piece  of  the  intestine  has.been  cut  away. 

spread  to  the  intestine  from  an  adjacent  part  and  has 
produced  obstruction  of  the  lumen  of  the  tube  so 
involved.  Thus  Mr.  McCarthy  has  recorded  a  case 
of  intestinal  obstruction  that  was  relieved  by  entero- 
tomy.  The  patient  lived  forty-eight  days  after  the 
operation.  The  autopsy  revealed  a  cancer  of  tlie 
splenic  flexure  that  had  spread  to  tlio  liowel  from  a 
primary  growth  in  the  stomach,  t 

*Bull.  de  la  See.  Anat.,  1873,  page  G13. 
fMed.-Chir.  Trans.,  1872. 


Chap. XII.]         Stricture:   Pathology.  277 

A  similar  spreading  has  been  noticed  in  connection 
with  malignant  disease  of  the  uterus. 

The  g^eiieral  patliolog^ical  eliaiiges  coii- 
seqiieiit  iipou  strictMre. — The  gut  above  the 
stenosis  becomes  dilated  and  its  walls  liypertrophied. 
In  long  standing  cases  this  hypertrophy  may  be  con- 
siderable and  far  spread.  Thus  in  cases  of  stricture 
of  the  sigmoid  flexure  not  only  has  the  colon  been 
found  dilated  and  liypertrophied,  but  also  the  terminal 
portion  of  the  ileum.  Often  above  the  stricture  is  a 
distinct  pouch  due  to  distension  acting  probably  upon 
walls  already  diseased.  The  walls  of  the  pouch  are 
thin,  the  mucous  lining  is  frequently  ulcerated,  and 
that  ulceration  often  leads  to  fatal  perforation.  These 
pouches  are  more  commonly  met  with  in  connection 
with  simple  than  with  malignant  strictures^  and  are 
much  more  common  in  the  small  than  in  the  large 
intestine.     (<S'ee  Fig.  53.) 

It  is  remarkable  in  how  many  cases  cherry  and 
plum  stones  have  been  found  in  these  pouches  or  in 
the  distended  intestine  above  a  simple  stricture.  The 
most  curious  case  of  this  kind  is  reported  by  Dr. 
Wickham  Legge.  The  patient,  a  female  aged  twenty- 
six,  for  several  years  before  her  death  evacuated,  on 
various  occasions,  cherry  stones  with  her  stools.  She 
also  vomited  a  few.  During  life  a  mass  of  cherry 
stone*  could  be  felt  through  the  parietes  giving  to  the 
hand  a  peculiar  sensation  as  they  were  rubbed  together. 
At  the  autopsy  a  stricture  of  the  ileo-caecal  valve  was 
found,  and  above  it  in  the  small  intestine,  an  imperial 
pint  of  fruit  stones.*  In  another  case  of  stricture  of 
the  ileo-ciecal  valve  nearly  a  litre  of  cherry  stones 
was  found  above  the  obstruction,  f  In  a  case  reported 
by  Dr.  Peacock  there  were  found  in  a  pouch  above  a 
stricture   of    the   small   intestine   thirty- three    plum 

*Path.  Soc.  Trans.,  vol.  xxi.,  page  171. 
+  L'Uiiion  M^d.,  1856,  No.  57. 


278  Intestinal  Obstruction.  •    [Chap.  xii. 

stones,  sixteen  cherry  stones,  and  six  orange  pips.* 
In  another  very  simihir  instance  there  were  only  throe 
plum  stones  in  the  pouch,  f  Lastly,  Dr.  Moore  has 
recorded  a  case  of  accumulation  of  a  large  number  of 
cherry  stones  above  a  sim})le  stricture  of  the  descend- 
ing colon.  I  In  most  of  the  instances  these  foreign 
bodies  had  led  to  perforation  of  the  bowel.  It  is  not 
improbable  that  the  habit  of  swallowing  fruit  stones 
had,  in  the  present  instances,  induced  the  simple 
stricture  that  was  found  in  each  case.  Or  it  may  be 
that  the  stricture  had  an  independent  origin  and  then 
induced  the  morbid  appetite.  A  third  alternative 
is  the  assumption  that  the  habit  of  swallowing  fruit 
stones  is  very  widespread. 

In  one  curious  case  of  stricture  of  the  lesser 
l)Owel  a  conical  pouch  or  funnel  was  found  to  hang 
down  into  the  lower  part  of  the  intestine.  It  had 
an  aperture  at  its  apex  and  through  it  all  the  faeces 
had  passed.  The  funnel-like  process  was  large  and 
conspicuous  and  is  well  depicted  in  Fig.  53.  §  It 
was  probably  produced  by  the  excessive  enlarge- 
ment of  a  simple  pouch  formed  above  the  stricture. 
The  fundus  of  the  pouch  would  be  pressed  against 
the  wall  of  the  gut  below  the  stricture,  until  at  last 
perforation  into  that  part  of  the  intestine  would  occur 
and  the  formation  of  the  funnel-like  process  would 
be  complete.  It  may  l)e  noted  that  in  the  specimen 
the  mucous  lining  of  the  process  can  be  seen  to  be 
continuous  with  that  of  the  intestine  above. 

It  is  common  to  find  about  simple  strictures  of  the 
lesser  bowel  certain  frajna  and  bars  of  cicatricial  tissue 
which  are  a})parently  the  jjroducts  of  an  irregular 
ulceration,  and  possibly  of  the  adhesions  of  adjacent 
inflamed  surfaces. 

*ratli.  Soc.  Trans.,  vol.  x.,  page  154. 

flbid.,  vol.  iv.,  page  152.       %  Lancet,  vol.  ii.,  1876,  page  505. 

§  St.  Thomas's  Hosp.  Museum,  No.  Q  129. 


Fig.  53.— Stricture  of  the  small  Intestine. 

a  and  «'  point  to  frjena  lioUling  in  position  a  remarkable  pouch  of  mucous  nieniT 

lirane. 


2 So  Intestinal  Obstruction.       [Chap. xii. 

The  distension  of  the  colon  above  a  stricture  may 
1)6  very  great.  Thus  in  a  case  of  epithelial  cancer  of 
the  sigmoid  flexure  causing  stricture,  reported  by  Dr. 
Fagge,"^  the  splenic  flexure  of  the  colon  was  found 
to  be  as  large  as  a  distended  stomach.  In  a  case  of 
stricture  of  the  splenic  flexure  by  the  same  author  the 
csecum  was  found  to  be  as  large  as  the  calf  of  the 
leg.  In  another  instance  where  the  stenosis  involved 
the  descending  colon,  the  large  intestine  above  tlie 
obstruction  had  a  diameter  of  from  eleven  to 
twelve  inches.!  The  enormous  distension  of  which 
the  colon  is  capable  is  well  illusti'ated  by  a  specimen 
in  St.  Bartholomew's  Hospital  Museum,  j  showing  the 
large  intestine  of  a  child  (who  died  of  rectal  stric- 
ture) that  has  a  diameter  of  more  than  one  foot. 

The  mucous  membrane  of  the  bowel  above  the 
obstruction  is  very  usually  ulcerated,  and  perforation 
caused  by  these  ulcers  is  a  common  cause  of  death 
after  stricture.  In  the  small  intestine  the  ulceration 
is  as  a  rule  situated  just  above  the  stenosed  part,  and 
if  perforation  occurs  it  will  occur  here.  There  are  a 
few  exceptional  cases.  Thus,  for  example,  in  a  case  of 
stricture  of  the  ileo-ctecal  valve  a  perforation  was 
found  to  have  taken  place  in  the  middle  of  the  ileum, 
and  on  the  other  hand  several  feet  of  the  small 
intestine  above  a  stricture  may  be  the  seat  of 
ulceration. 

As  regards  the  colon,  the  whole  of  its  mucous 
inembrane  above  the  stricture  may  be  ulcerated,  but 
as  a  rule  the  ulceration  is  much  more  limited.  When 
the  stricture  is  at  some  distance  from  the  valve 
ulceration  may  be  noted  in  two  distinct  places,  viz. 
just  above  the  obstruction  and  in  the  caecum,  the 
intervening  mucous  membrane  being  qiiite  healthy. 

*  Guy's  Hosp.  Reports,  vol.  xiv.,  page  272. 
■\  Lanctt,  vol.  ii.,  1870,  page  505. 
J  No.  1,952. 


Chap,  xii.j        Stricture :  Pathology.  281 

This  lias  been  met  with  several  times  in  stricture 
of  the  sigmoid  flexure.  When  perforation  occurs  in 
colic  strictures  the  abnormal  aperture  may  be  either 
just  above  the  stricture  or  in  the  csecum.  The 
relative  proportion  of  perforation  in  these  two  places 
is  as  seven  to  four. 

In  several  cases  where  ulcers  have  been  found  in 
the  csecum  similar  lesions  have  been  at  the  same  time 
met  with  in  the  ileum.  In  one  instance  of  simple 
stricture  of  the  splenic  flexure  there  was  an  annular 
ulcer  in  the  colon  just  above  the  obstruction  and  six 
large  ulcers  in  the  lower  end  of  the  ileum.  No  other 
part  of  the  bowel,  not  even  the  caecum,  was  involved. 
A  fatal  perforation  had  occurred  in  the  lower  ileum. "^ 

The  perforating  ulcer  above  the  stricture  need  not 
open  into  the  peritoneal  cavity.  In  a  few  rare  cases 
where  adhesions  have  formed  the  perforation  has 
been  so  placed  as  to  give  temporary  relief  at  least  to 
the  obstruction.  Thus  in  one  case  of  stricture  of  the 
valve,  the  ileum  ojDened  into  the  commencement  of 
the  colon,  forming  a  fistula  bimucosa  through  which 
the  f?eces  could  pass.f  Other  cases  of  relief  by  the 
formation  of  such  a  fistula  have  been  reported  ;  also 
an  instance  where  the  colon  above  a  stricture  in  a 
distorted  sigmoid  flexure  Avas  found  to  have  opened 
into  the  bladder  and  rectum.  | 

Sometimes  the  changes  in  the  bowel  above  the 
obstruction  pass  the  limits  of  ulceration  and  the  part 
becomes  gangrenous.  Gangrene  developed  under  these 
circumstances  is  usually  found  in  obstructions  of  the 
colon  only,  and  it  is  only  in  this  part  of  the  intestine 
that  gangrene  of  an  extensive  character  is  met  with. 
Dr.  Moxon  has  recorded  a  good  example  of  this  con- 
dition.    The  stricture  was  in  the  sigmoid  flexure,  the 

*  Bull,  de  la  Soc.  Anat.,  1870,  page  27. 
fPath.  Soc.  Trans.,  vol.  xxi.,  page  171. 
J  Ibid.  J  vol.  i.,  page  264. 


282  Intestinal  Obstruction.       [Chap.  xii. 

patient  an  adult.  The  anterior  wall  of  the  ascending 
colon  was  wanting  (having  sloughed)  over  an  area 
measuring  five  inches  by  one  and  a  half  inches. 
Escape  of  the  contents  had,  however,  been  prevented 
by  the  great  omentum,  which  had  become  adherent 
over  the  gap  and  had  closed  it."^  Dr.  Goodhart  has 
placed  upon  record  a  still  more  pronounced  instance. 
In  this  case  the  stricture  was  also  at  the  sigmoid 
flexure  and  the  patient  an  adult.  A  great  part  of 
the  transverse  colon  and  nearly  the  whole  of  the 
descending  colon  were  gangrenous,  the  mucous  mem- 
brane here  being  especially  involved.!  Cases  of  less 
extensive  gangrene  leading  to  rupture  of  the  gut  are 
fairly  common.  The  gangrene  in  these  instances  is 
due  partly  to  obliteration  of  the  vessels  in  the 
intestinal  wall  by  pressure  and  distension,  and  partly 
to  the  irritating  action  of  retained  fseces. 

When  the  colon  is  involved  in  a  stenosis  at  the 
point  of  junction  of  the  sigmoid  flexure  with  the 
rectum,  the  flexure  often  becomes  much  distorted 
from  distension.  When  so  distended  it  may  reach 
remote  parts  and  become  adherent  to  them.  Thus  it 
has  been  found  to  be  adherent  to  the  pelvic  peri- 
toneum, to  the  Vjladder,  and  to  the  serous  lining  of 
the  right  iliac  fossa. 

Tlie  c'onclitioii  of  the  sli'ii'liii'c  in  its  rcla- 
tioii  to  the  clinical  aspect  of  the  case.— The 
stricture  at  the  time  of  death  may  be  wide  enough  to 
admit  the  tip  of  the  fore-finger  ;  on  the  other  hand  it 
may  be  so  narrow  that  water  will  merely  trickle 
through  it  in  drops,  or  it  will  admit  only  a  probe  or  a 
goose-quill.  As  a  rule  the  narrowest  strictures  are 
met  with  in  the  small  intestine,  although  there  are 
cases  of  stenosis  of  the  colon  where  the  obstructed 
part   has,    at    the   time    of    death,    only    allowed   a 

*Path.  Soc.  Trans.,  vol.  xx.,  page  181. 
t  Ibid.,  vol.  xxxi.,  i»:ige  113. 


Chap.  XII.]         Stricture :  Patiiology.  283 

common  probe  to  pass.  Such  extreme  cases  are, 
however,  rare  in  the  larger  bowel.  A  stricture  can 
attain  to  narrow  dimensions  without  producing  a 
rapidly  fatal  result  wh(!n  the  contents  of  the  part 
of  the  bowel  that  it  involves  are  fluid.  This  is  one 
reason  why  narrower  strictures  are  more  possible  in 
the  small  than  in  the  large  intestine.  In  Fig.  47  is 
shown  a  narrow  stricture  of  the  jejunum  that  never 
caused  obstruction  symptoms,  the  patient  dying  with 
diarrhoea.  Messrs.  Coupland  and  Morris  in  their 
monograph  allude  to  a  case  of  annular  stenosis  of  the 
jejunum  that  was  so  narrow  as  to  only  admit  a  No.  7 
catheter,  and  yet  the  patient  presented  no  intestinal 
symptoms  during  life.  In  like  manner,  if  the  contents 
of  the  colon  be  fluid,  strictures  of  that  gut  that  are 
comparatively  narrow  may  cause  no  symptoms  of 
obstruction.  Such  patients  die  with  severe  and  per- 
sisting diarrhosa.  Many  cases  have  been  recorded 
where  this  part  of  the  bowel  at  the  autopsy  has 
appeared  almost  quite  blocked  by  a  cancerous  new 
growth  or  by  deposits  of  lympho-sarcoma,  and  yet  the 
patient  has  presented  no  symptoms  of  obstruction. 
The  contents  of  the  colon  have  remained  in  a  fluid 
condition  and  death  has  followed  upon  a  long  abiding 
diarrhoea. 

The  precise  manner  in  which  a  stricture  of  the 
intestine  brings  about  the  death  of  a  patient  is  by  no 
means  the  same  in  every  case. 

In  some  instances  the  stricture  becomes  narrower 
and  narrower,  the  obstruction  becomes  by  slow  degrees 
more  and  more  complete  until  at  last  it  causes  death, 
after  following  a  chronic  and  lingering  course.  In 
other  cases  the  stricture,  having  obstructed  the  bowel 
to  a  certain  extent,  appears  to  undergo  no  further 
contraction,  but  the  patient  dies  worn  out  by  the  long 
continued  abdonnnal  troubles,  or  succumbs  to  an 
increasing  marasmus.     In  cases  of  malignant  disease 


284  Intestinal  Obstruction.        [Chap.  xii. 

also  the  effect  of  the  morbid  growth  upon  the  patient's 
general  condition  must  not  be  overlooked.  There  are 
cases  that  for  a  while  adopt  a  lingering  progress  and 
then  end  somewhat  more  abruptly.  That  is  to  say, 
for  some  considerable  time  the  malady  may  present 
the  symptoms  of  a  chronic  obstruction,  and  the  fatal 
issue  be  brought  about  by  an  attack  of  acute  obstruc- 
tion. Instances  of  this  kind  depend  upon  many 
diflferent  pathological  conditions.  Thus  a  plug 
of  hard  faecal  matter  may  have  blocked  up  a 
stricture  that  had  of  itself  caused  no  very  serious 
amount  of  obstruction."^  Or  this  blocking  of  the 
stenosed  part  may  have  been  brought  about  by  some 
foreign  substance.  Thus  in  a  case  reported  by  Dr. 
Peacock  a  dry  raisin  was  found  impacted  in  the 
stricture,!  while  in  another  specimen  the  final  occlu- 
sion of  the  already  narrowed  bowel  has  been  brought 
about  by  a  cherry  stone.  |  In  other  instances  folds  of 
mucous  membrane  from  the  gut  above  the  stenosed 
part  may  so  fall  across  the  orifice  of  the  stricture  as 
to  close  it  like  a  valve.  In  these  cases  water  may 
be  injected  with  ease  from  below,  but  only  wdtli 
much  difiiculty  from  above.  To  cases  such  as  these 
must  be  added  that  extensive  series  where  the 
small  intestine  at  the  seat  of  the  stiicture  has 
become  so  bent  as  to  have  its  lumen  more  or  less 
abruptly  occluded,  or  where  "  kinking  "  has  occurred, 
or  where  the  narrowed  bowel  has  become  still  more 
occluded  by  adhesions  and  by  matting  of  its  coils 
together. 

In  stricture  of  the  sigmoid  fiexure,  moreover,  an 
acute  termination  to  the  case  is  by  no  means  un- 
common. The  greatly  distended  "  flexure "  becomes 
bent  upon  itself    and  thereby  occluded,  or   its  parts 

*Dr.  Piatt;  Lancet,  vol.  i.,  1873,  page  42. 

fDr.  Peacock;  Path.  Soc.  Trans.,  vol.  xiii.,  page  137, 

I  St.  Bart.'s  Hosp.  Museum,  No.  2,017. 


Chap.  XIII.]        Stricture  :   Svmptoms.  285 

are  so  arranged  that  a  volvulus  is  produced,  or  the 
extremity  of  its  loop  contracts  adhesions  that  may 
serve  to  fui'ther  narrow  the  lumen  of  the  bowel. 


CHAPTER    XIII. 

THE    SYMPTOMS    AND    PROGNOSIS    OF    STRICTURE    OF    THE 

INTESTINE. 

Position.  Age.  Sex.— I  have  collected  twenty- 
six  cases  of  stricture  of  the  small  intestine,  eight  cases 
of  stricture  of  the  ileo-cfecal  valve,  and  forty-four  of 
stenosis  of  the  colon. "^  Total  seventy-eight.  Of  this 
number  thirty-five  were  males  and  forty-three  females. 

The  cases  are  thus  distributed  : 

1    10  cases  of  cicatrix   after  ulcer     {  ^  ?^^^^f 
26  cases  of  stric-  I  *     ■     ,  •       .^      •    •  ^t  females. 

ture     of    the  '      ^      »»     of  cicatrix  after  injury       2  males. 

small       intes-  f     4      „     following  strang.  hernia     {  ^  f^nial 


tine. 


females. 

!    10      „     of  cancer        .         .         .     1 5  f '^^^^ 
j  "  ( o  females. 


26  15  males  11  females. 

The  average  age  of  the  ten  patients  with  cicatri- 
cial strictures  after  ulcer  was  thirty-five.  The  youngest 
was  a  child  of  nine.  The  rest  were  between  twenty- 
one  and  fifty-eight  years  of  age. 

The  average  age  of  the  ten  patients  with  cancer 
was  forty-two  ;  the  youngest  being  thirty-seven,  the 
oldest  sixty-five. 

The  ages  of  the  four  patients  with  stricture  fol- 
lowing hernia  were  twenty-six,  thirty-four,  fifty-two, 
and  fifty-seven.  (Three  of  the  hernije  were  inguinal 
and  one  was  femoral.) 

*  The  last-named  are  exclusive  of  the  cases  collected  by  Dr. 
Fagge  and  by  Messrs.  Coupland  and  Morris. 


286 


Intestinal  Obstruction.      [Chap.  xiii. 


8  cases  of  stric- 
ture of  the 
ileo-cacalvalie. 


3  cases  of  simple  stricture 


44  cases  of  stric-  ! 
ture      of      the  )• 
colon.  I 

J 


28 
13 


simple  stricture 
natui'e  unknown 


(  1  male 

(  2  females. 

(  1  male 

'    \  4  females. 

2  males  G  females. 

( 14  males 
*     (  14  females. 
(    2  male 
(  11  females, 
f    2  males 
(    1  female. 

44  18  males  26  females. 

The  average  age  of  the  twenty-eight  patients  witli 
cancer  was  forty-eight.  Only  six  were  under  forty 
years  of  age.  The  youngest  patient  was  t\\'enty-two  ; 
the  oldest  sixty-six. 

The  average  age  of  the  thirteen  patients  with  non- 
cancerous stricture  was  forty-four,  the  youngest  being 
nineteen  and  the  oldest  seventy-six. 

The  situation  of  the  stricture  in  the  forty-four 
cases  was  as  follows  : 

Sigmoid  flexiu'e  .  .  .  .  .27 
Descending  colon  .....  5 
Splenic  flexure  .....  2 
Transverse  colon  .....  3 
Hepatic  flexure  .....  5 
Ascending  colon  ....  .1 
Ctecum  ....         .         .         .1 

Adding  to  my  forty-four  cases  sixteen  that  were 
collected  by  Dr.  Fagge,  and  thirty- eight  by  INIessrs. 
Coupland  and  Morris,  the  following  result  is  o))- 
tained  in  the  total  of  ninety- eight  cases  : 

Sigmoid  flexure  .....  58 
Descending  colon  .         .         .         .         .11 


Splenic  flexure 
Transverse  colon 
Hepatic  flexure 
Ascending  colon 
Caecum 


Total 


98 


Chnp.  xin.]         Str/cture:   SvMrronTS.  287 

The  following  general  conclusions  may  ha  drawn 
from  the  al)Ovo  statistics  : 

Stricture  of  the  intestine  is  a  little  more  common  in 
females  than  in  males.  In  one  fomi  of  stenosis,  how- 
ever (viz.  ill  the  non-cancorous  stricture  of  the  colon), 
the  num])(!r  of  females  is  greatly  in  excess  of  the 
males,  the  proportion  being  as  eleven  to  two.  As  re- 
gards the  ages  of  tlie  patients  it  will  he  seen  that  this 
malady  is  pi-actically  limit(Ml  to  adults.  Cases  of 
cancer  are  extremely  rare  before  forty,  while  cicatri- 
cial strictures  are  met  with,  taking  the  average,  at  a 
slightly  (^arli(!r  ag(;. 

Pr<^vioiis  liBsloi'y.— Facts  in  connection  with 
the  previous  history  of  pati(nits  suflV^j-iug  from  stric- 
ture of  the  iiit(!stine  are  of  comparatively  little  value. 
Many  of  the  stenoses  follow,  as  we  have  seen,  upon 
ulceration.  Certain  forms  of  intestinal  ulceration  are 
associated  with  very  definite  symptoms,  as  is  the  case 
in  typhoid  fever  and  dysentery.  A  history  of  dysen- 
tery is  of  much  vahie  in  tlie  clinical  account  of  cer- 
tain of  tlujse  cases,  since  many  of  tlie  cicatricial 
strictures  of  the  large,  intestine  depend  upon  this 
malady.  A  history  of  ty))hoid  fever,  on  the  other 
hand,  is  practically  v^aku^hiss,  on  account  of  th(^ 
extreme  rarity  of  stenosis  of  the  bowel  as  a  conse- 
fjuence  of  tlui  disease.  The  frequency  of  syphilis  and 
the  rarity  and  the  indefiniteness  of  syphilitic  aftectibns 
of  the  bowel  above  the  rectum  render  the  evidences  of 
that  disorder  in  any  given  patient  of  little  use  in 
atte'mpting  a  diagnosis  of  the  case.  A  history  of 
tuberculosis  in  any  case,  or  the  presence  of  any  evident 
tubercular  malady,  may  suggest  a  stenosis  due  to  tuber- 
cular ulceration  in  instances  where  symptoms  of  ob- 
struction of  the  bowel  appear.  The  suggestion,  how- 
ever, would  be  as  feeble  as  it  is  indefinite. 

In  connection  with  the  less  precise  forms  of  intes- 
tinal ulceration    it    juust    be   remembered  that  even 


288  Intestinal  Obstruction.       [Chap. xiii. 

extensive  disease  in  the  tube  may  be  attended  by  no 
symptoms.  It  is  by  no  means  uncommon  to  find  at 
an  autopsy  ulcers  in  the  bowel  that  gave  not  the  least 
evidence  of  their  existence  during  life.  Indeed,  if  one 
make  exception  of  typhoid  and  dysentery  I  tliink  it 
may  be  said  that  ulceration  of  the  intestine  is  asso- 
ciated -svith  symptoms  so  vague,  so  uncertain,  and 
frequently  so  contradictory,  that  the  malady  can 
hardly  be  said  to  have  a  clinical  existence.  Many 
examples  may  be  given  in  illustration  of  this.  One 
may  be  selected.  Dr.  Fuller  reports  the  case  of  a 
man  aged  fifty,  who  suftered  for  six  months  before  his 
death  with  general  and  progressive  wasting.  He  had 
no  abdominal  symptoms  of  any  kind.  His  bowels 
were  always  regular  and  his  motions  natural.  He  was 
never  sick  and  had  no  tenderness  over  the  belly.  He 
died  suddenly  of  perforative  peritonitis.  The  autopsy 
revealed  extensive  ulceration  of  the  ileum,  nearly  the 
whole  of  that  segment  of  the  gut  being  involved. 
Indeed,  in  a  length  of  five  feet  of  that  bowel  there 
were  no  less  than  twenty-five  large  ulcers.  One  of 
these  had  caused  perforation.  There  were  some  ulcers 
also  in  the  colon.  In  nature  they  were  supposed  to 
have  been  tubercular.* 

In  cases  where  symptoms  are  excited  there  may 
be  constipation,  but  more  frequently  diarrhoea.  Some- 
times blood  is  found  in  the  evacuations  in  cases  of 
disease  in  the  colon,  and  when  the  ulceration  involves 
the  lower  part  of  this  bowel  tenesmus  is  not  uncom- 
mon. There  may  be  some  pain  in  the  abdomen,  but 
it  is  very  indefinite  and  usually  most  insignificant. 
As  a  rule  vomiting  only  occurs  in  cases  of  duodenal 
ulcer,  and  in  instances  where  the  peritoneum  is  in- 
flamed. Leube  observes  that  in  the  case  of  the  so- 
called  follicular  ulcer  small  plugs  of  mucus  like  sago 
grains  may  be  passed  with  the  stools. 

*Path-  Soc.  Trans.,  vol.  xi.,  page  103, 


Chap.  XIII.]        Stricture:  Symptoms.  289 

Among  other  elements  in  the  etiology  of  stricture 
that  may  be  displayed  in  the  history  of  the  ease,  are 
injury  to  the  abdoirien,  strangulated  hernia,  typhlitis, 
perityphlitis,  and  diarrhoia.  If,  however,  we  consider 
the  frequency  of  these  affections  on  the  one  hand  and 
the  comparative  rarity  of  cicatricial  stricture  of  the 
bowel  on  the  other,  it  will  be  seen  that  a  history  of 
any  of  these  affections  in  a  suspected  case  will  be  of 
but  little  clinical  value. 

As  to  the  interval  of  time  that  elapses  between 
the  causative  affection  and  the  symptoms  of  obstruc- 
tion of  the  bowel;  the  greatest  uncertainty  exists. 
Much  depends  obviously  upon  the  extent  of  the  initial 
lesion.  The  only  fact  that  is  to  any  extent  constant 
is  the  circumstance  that  the  evidences  of  stenosis  Avill 
appear  at  an  earlier  date  when  the  lesser  bowel  is  in- 
volved than  is  the  case  when  the  stricture  implicates 
the  colon. 

In  two  cases  of  stricture  of  the  small  intestine 
following  injury,  three  and  four  months  respectively 
intervened  between  the  lesion  and  the  appearance  of 
obstruction  symptoms.  In  four  cases  of  stenosis  of 
the  ileum  following  upon  strangulated  hernia,  the 
interval  that  elapsed  between  the  reduction  of  the 
rupture  and  the  onset  of  symptoms  of  stricture  was 
one  month,  six  weeks,  seven  months,  and  "  some 
years  "  respectively. 

With  regard  to  the  large  intestine  I  find  that 
periods  often  of  several  years  have  elapsed  between 
an  attack  of  dysentery  and  the  appearance  of  obstruc- 
tion symptoms  due  to  contraction  of  the  dysenteric 
cicatrices.  Rokitansky  mentions  a  case  where  symp- 
toms of  constriction  of  the  bowel  did  not  appear 
until  thirty  years  after  an  attack  of  dysentery.  I  find 
a  case  of  stricture  of  the  ileo-colic  valve  that  induced 
symptoms  eleven  years  after  a  typhlitis,  and  an  in- 
stance of  stricture  of  the  hepatic  flexure  of  the  colon 
T— 12 


290  Intestinal  Obstruction.      [Chap.  xiii. 

that  produced  evidences  of  constriction  twelve  months 
after  an  attack  of  severe  diarrhoea. 

The  symptoms  that  precede  the  actual  evidences 
of  obstruction  in  cases  of  cancerous  stricture  will  be 
considered  when  dealing  with  the  general  symptoms 
of  those  stenoses. 

THE    SMALL    INTESTINE— SIMPLE    STRICTURE. 

Mode  of  onset  and  general  course. — The 

simple  stricture  of  the  small  intestine  belongs  dis- 
tinctly to  the  chronic  variety  of  intestinal  obstruction. 
The  symptoms  are  usually  extended  over  a  compara- 
tively long  period  of  time,  and  become,  as  th§  case 
advances,  progressively  worse.  The  stenosed  canal 
simply  becomes  narrower  and  narrower  until  at  last 
it  produces  a  degree  of  obstruction  that,  either  from  its 
long  duration  or  its  completeness,  leads  to  results  that 
produce  death.  Thus  it  liappens  that  many  cases  of 
this  form  of  constriction  develop  very  slowly  and  very 
insidiously,  follow  a  tedious  course  and  bring  about 
gradually  a  fatal  result.  While  this  can  be  said  of 
many  cases  it  cannot  be  said  of  the  majority.  Owing 
to  the  fluid  character  of  the  contents  of  the  small  in- 
testine it  happens  that  the  stenosis  may  become  pro- 
nounced before  very  serious  symptoms  are  produced. 
But  the  narrow  stricture  is  constantly  liable  to  be 
abruptly  closed.  A  valvular  fold  of  mucous  mem- 
brane is  laid  across  it,  or  it  becomes  suddenly  plugged 
by  a  mass  of  undigested  food,  or  a  foreign  substance 
that  has  been  swallowed,  or  the  involved  coil  of  gut 
may  become  abruptly  closed  by  kinking  or  by  some 
of  those  methods  of  producing  obstruction  that 
depend  upon  adhesions. 

Thus  it  happens  that  in  the  clinical  history  of 
stricture  of  this  bowel  we  very  often  find  the  symp- 
toms of  chronic  obstruction  ending  in  an  attack  of 
acute    obstruction   that  has    a    fatal    issue.       Before 


Chap.xiii.i         Stricture:  Symptoms.  291 

the  final  attack  the  patient  may  have  had  several 
previous  attacks  of  similar  nature,  from  which, 
however,  he  has  recovered,  the  lumen  of  the  tube 
becoming  restored.  Lastly  it  may  be  that  the  bowel 
has  become  gradually  much  narrowed  without  any 
symptoms  having  been  excited  that  have  caused 
attention.  The  narrowed  tube  is  suddenly  occluded 
by  some  of  the  means  just  alluded  to,  symptoms  of 
acute  obstruction  develop  which  may  rapidly  lead  to 
death.  Thus  there  are  cases  of  cicatricial  stricture 
of  the  lesser  bowel  that  have  appeared  with  all  the 
evidences  of  acute  obstruction,  the  patient  having 
been  free  from  any  marked  symptoms  of  abdominal 
trouble  at  the  time  of  the  onset  of  the  attack. 
Examples  of  such  cases  will  be  detailed  subsequently. 

Symptoms. — The  course  of  the  disease  is  ex- 
tremely irregular  and  is  marked  by  great  fluctuations 
in  tlie  occurrence  and  nature  of  the  symptoms. 

The  most  conspicuous  and  constant  feature  con- 
sists in  certain  attacks  of  paroxysmal  pain  that 
occur  at  intervals.  The  pain  in  these  attacks  is  of  the 
nature  of  colic  and  is  often  severe.  It  is  associated 
with  constipation  and  is  usually  attended  by  vomiting. 
The  colicky  pains  are  often  described  as  radiating 
from  the  navel,  and  are  never,  so  far  as  I  can  ascer- 
tain, distinctly  localised  in  any  one  part.  It  is  most 
significant  to  note  that  these  attacks  usually  come  on 
after  food,  and  as  a  rule  some  three  or  four  hours 
after  the  taking  of  the  food.  Sometimes  they  appear 
at  a  shorter  interval  after  meals,  but  very  rarely  at  a 
longer.  These  attacks  may  begin  most  insidiously, 
may  appear  in  patients  who  present  absolutely  no 
abdominal  symptoms,  or,  as  is  more  usual,  come  on 
after  a  long  continued  intestinal  disturbance,  some- 
times marked  by  diarrhoea,  but  more  often  by  consti- 
pation. At  the  commencement  the  patient  often 
complains  merely  of  indigestion  and  flatulency  after 


292  Intestinal  Obstruction.      ;chnp  xiii. 

food.  In  time  the  attacks  become  more  definite 
and  more  severe,  until  at  last  the  individual  is  liable 
from  time  to  time  to  sharp  paroxysms  of  colic  asso- 
ciated with  vomiting  and  other  symptoms. 

In  other  instances  the  individual  attacks  are  some- 
what severe  from  the  first.  They  may  appear  once  a 
month  or  once  in  three  or  four  months.  They  may 
last  several  hours  or  even  days.  During  the  inter- 
vals between  their  appearance  the  patient  may  be 
well,  or  have  a  little  indigestion,  or  be  troubled,  as  is 
very  common,  with  constipation,  or  with  diarrhoea 
alternating  with  constipation. 

In  any  case,  as  time  advances  the  attacks  occur 
more  and  more  frequently,  while  at  the  same  time 
they  lessen  in  duration.  At  last  the  patient  may 
have  attacks  of  pain  every  few  hours  or  every 
quarter  of  an  hour,  each  attack  not  lasting  probably 
more  than  two  or  three  minutes.  There  is  every 
reason  to  believe  that  the  attacks  of  pain  are  due  to 
a  temporary  blocking  of  the  stricture.  This  blocking 
is  effected  by  imperfectly  digested  food  or  faecal 
matter,  aided  possibly  by  some  kinking  of  the  bowel 
incident  to  peristaltic  movements  passing  through  a 
diseased  segment  of  intestine.  In  some  cases  it  is 
possible  that  kinking  is  a  conspicuous  feature  in 
these  attacks.  So  long  as  the  stricture  is  of  good 
size  it  will  be  obvious  that  these  obstructive  attacks 
can  only  occasionally  occur,  and  thus  we  find  that 
they  appear  at  very  irregular  intervals ;  at  first  at 
intervals  that  may  sometimes  be  reckoned  by  months, 
and  at  others  by  weeks  or  even  days.  As  the  stric- 
ture becomes  narrower  the  obstruction  becomes  more 
abiding. 

The  attacks  become  much  more  frequent  and  more 
constant  and  at  the  same  time  their  duration  is 
lessened.  The  obstructive  paroxysms  are  now 
brought  about  bv  ordinary  intestinal  matters  and  are 


Chap.  XIII,]        Stricture  :  Symptoms.  293 

not  dependent  upon  exceptional  masses  of  unassimi- 
lated  food. 

The  association  of  these  attacks  with  the  ingestion 
of  food  is  a  matter  of  great  importance  and  of  much 
diagnostic  value.  Usually  the  patient  recognises  the 
association  and  has  to  exercise  great  care  in  his  diet. 
In  several  instances  the  attacks  were  warded  off  for 
a  long  while  by  adopting  a  perfectly  fluid  diet,  and 
reappeared  at  once  on  any  relaxation  of  the  rule. 

Some  of  the  earlier  attacks  are  not  unlike  attacks 
of  subacute  obstruction,  but  as  the  case  advances  the 
chronicity  of  its  course  becomes  evident.  The  patient 
is  seen  to  be  suffering  from  some  grave  intestinal  dis- 
turbance associated,  among  other  features,  with  attacks 
of  joain  that  are  of  a  paroxysmal  character  and  appear 
at  frequent  intervals. 

In  most  instances  the  patient  dies  of  a  definite  ob- 
structive attack.  The  stricture  becomes  actually  or 
practically  closed,  and,  no  passage  being  re-established, 
death  ensues. 

It  is  well  to  note  that  when  complete  obstruction 
sets  in  the  character  of  the  pain  changes.  It  be- 
comes continuous,  being,  however,  at  the  same  time 
liable  to  exacerbations  at  intervals.  Unlike  the  pre- 
vious attacks,  the  patient  is  not  now  free  from  pain  in 
the  intervals. 

Vomiting  in  these  cases,  although  a  constant 
symptom,  is  by  no  means  a  very  pronounced  or  dis- 
tressing one.  During  the  more  severe  of  the  earlier 
attacks  (attacks  that  occur  at  long  intervals  and  last 
some  time)  vomiting  is  present.  It  appears  late 
and  is  often  scanty.  If  the  attack,  however,  last  for 
some  time,  a  matter  of  days,  the  vomiting  is  apt  to 
become  feculent,  although  examples  of  this  are  in- 
frequent. 

As  a  rule  the  vomiting  only  becomes  feculent 
towards    the    termination     of     the    final    attack   of 


294  Intestinal  Obstruction.      tChap.  xiii. 

obstruction.  In  these  attacks  it  may  be  severe,  but 
it  scarcely  ever  reaches  the  severity  of  the  vomiting 
seen  in  cases  of  acute  obstruction. 

The  symptom  shows  great  fluctuation.  During 
the  final  attack  of  occlusion  the  vomited  matters  may 
become  feculent,  the  sickness  may  then  abate  and 
only  alimentary  and  bilious  matters  be  rejected. 
After  awhile  the  vomit  may  again  become  stercora- 
ceous.  The  symptom  depends  in  a  marked  manner 
upon  the  degree  of  the  obstruction,  and  faecal  vomit- 
ing never  appears  until  absolute  constipation  has  be- 
come a  pronounced  feature. 

As  may  be  gathered  from  what  has  been  already 
said,  the  state  of  tlie  too-ivels  is  subject  to  the 
greatest  variation.  In  about  60  per  cent,  of  the  cases 
constipation  is  the  predominant  feature.  In  some- 
thing less  than  40  per  cent,  there  is  constipation  alter- 
nating with  diarrhoea ;  but  in  only  a  very  few  cases 
is  diarrhoea  the  more  usual  condition  of  the  bowels. 
During  the  initial  attacks,  and  during  the  final  attack, 
constipation  is  almost  invariable  and  may  remain 
absolute  for  many  days  or  even  for  two  or  for  three 
weeks.  The  constipation  at  first  yields  to  treatment, 
but  soon  becoDies  more  and  more  obstinate.  It  is  im- 
portant to  note  that  the  earlier  attacks  are  often  at 
once  relieved  by  an  ajierient.  The  purge  would  not 
only  render  the  intestinal  contents  more  fluid,  but 
would  remove  the  cause  of  the  obstruction,  if  it  be  a 
mass  of  undigested  matter.  Like  relief  may  follow 
the  use  of  an  enema. 

Sometimes  an  attack  of  long-contmued  constipa- 
tion is  suddenly  relieved  by  a  copious  and  sjjontaneous 
stool.  In  such  cases  the  plug  or  other  obstructing 
agent  has  probably  abruptly  yielded. 

It  is  not  very  uncommon  for  the  patient,  after  days 
or  weeks  of  absolute  obstruction,  to  pass  a  copious 
motion  just  before  death.     This  indicates,  I  think,  in 


Chap.  XIII.]        Stricture:  Svmptoms.  295 

nearly  every  case  a  perforation  of  the  bowel.  A 
pressure  within  the  intestine  is  removed  by  this  per- 
foration, and  one  factor  in  the  production  of  the 
occlusion  being  removed,  the  stricture  yields  for  the 
last  time. 

In  only  one  case  was  there  any  teiiesmiis.  It 
was  in  a  case  of  stricture  following  strangulated  hernia, 
and  was  apparently  very  slightly  marked.  The 
stenosis  was  in  the  lower  part  of  the  ileum.* 

As  regards  the  general  condition  of  the 
patients,  it  only  remains  to  be  said  that  they  become 
progressively  weaker  as  the  disease  advances,  being 
worn  out  by  the  frequent  attacks  of  pain  and  vomiting 
and  enfeebled  by  the  loss  of  appetite  that  is  often  a 
conspicuous  symptom.  Emaciation  is  usually  pro- 
nounced, and  the  patient's  wasted  and  cachectic  aspect 
may  be  such  as  to  suggest  the  presence  of  malignant 
disease. 

The  state  of  the  abdomen. — The  abdominal 
walls  remain  flaccid  except  during  some  of  the  more 
painful  paroxysms  or  after  the  development  of  peri- 
tonitis. 

During  the  duration  of  the  attacks  of  obstruction 
there  will  be  some  meteorism  which,  however,  is  never 
excessive.  In  the  intervals  between  the  attacks  the 
abdomen  will  not  be  swollen,  and  its  walls  indeed  are 
commonly  retracted  in  cases  associated  with  much 
wasting  and  with  diarrhoea. 

It  is  very  usual  for  the  movements  of  the  intestinal 
coils  to  be  visible  through  the  parietes,  a  circum- 
stance that  is  to  be  especially  noticed  during  the 
paroxysms  of  pain. 

In  no  instance  among  the  rejjorted  cases  was  any 
tumour  to  be  felt^  nor  any  localised  dullness  present 
that  could  assist  in  the  diamosis  of  the  ailment. 

*Bti11.  et  IMem.  de  la  Soc.  cle  Chir.,  tome  vi.,  1880,  page  607; 
M.  Berger. 


296  Intestinal  Obstruction.      [Chap.xiil. 

Cases  %vitli  an  acute  course. — It  has  already 
been  said  that  cases  of  stricture  of  the  lesser  bowel 
are  usually  attended  by  certain  painful  attacks  at 
intervals,  which  indicate  a  temporary  obstruction  of 
the  strictured  part.  It  may  be  readily  understood 
that  the  first  occurrence  of  this  obstruction  may  also 
be  the  last ;  that,  in  fact,  the  stenosis,  after  existing  for 
some  time  without  causing  symptoms,  may  become 
suddenly  occluded,  and  that  that  occlusion  may  bring 
about  a  fatal  issue.  Such  a  case  is  reported  by 
liefrege.  It  concerns  a  man,  aged  forty-nine,  who 
had  been  liable  for  some  months  to  constipation. 
For  some  days  before  his  admission  into  hosj)ital  he 
had  had  some  pain  in  the  lower  part  of  his  abdomen. 
On  admission  the  limbs  were  cold  and  cyanosed,  the 
face  livid,  the  eyes  sunken,  the  patient  much  troubled 
by  vomiting,  and  the  pulse  very  small  and  feeble. 
There  was  constipation.  An  epidemic  of  cholera 
existed  at  the  time,  and  the  case  was  taken  for  an 
example  of  that  disease.  The  patient  was  treated 
with  hot  baths  and  by  such  measures  as  were  then  in 
vogue  for  the  treatment  of  cholera.  He  died  on  the 
eighth  day  after  admission.  Before  his  death  ster- 
coraceous  vomiting  had  occurred  and  the  general 
character  of  the  case  had  been  recognised.  The 
autopsy  revealed  a  stricture  in  the  lower  ileum  that 
would  barely  admit  a  crow-quill.*  Another  very 
interesting  case  is  rej^orted  by  Dr.  Piatt.  In  this 
instance  the  patient,  a  child  aged  nine,  appears  to  have 
had  no  evidence  of  previous  abdominal  trouble.  The 
symptoms  of  obstruction  appeared  suddenly,  and 
rapidly  assumed  an  aspect  of  gieat  gravity.  Death 
took  place  on  the  seventh  day.  The  case  had  been 
diagnosed  as  acute  intussusception.  The  autopsy 
revealed  a   stricture  of  the   lower   extremity   of  the 

*Le  Diagnostic  de  I'^lStranglement  intestinal  a  Symptoraes 
clioleri  formes,  by  Felix  Ryfz-ege.     Paris,  18G7. 


ciiap.  XIII.]        Stricture  :  Symptoms.  297 

ileum,   which  had  become    obstructed   by  a  plug  of 
clayey  feces.* 

THE    SMALL    INTESTINE — CANCEROUS    STRICTURE. 

The  sjTiiptoiiis  of  this  form  of  stenosis  are  practi- 
cally identical  with  those  just  detailed  as  incident  to 
simple  stricture.  In  perhaps  the  majority  of  cases 
it  would  not  be  possible  to  distinguish  one  from  the 
other.  Taking  a  general  view  of  the  cases  collected, 
it  will  be  seen  that  in  "cancerous"  stenosis  there 
are  the  same  paroxysmal  attacks  of  pain  and  the 
same  general  symptoms  with  regard  to  the  state  of 
the  bowel,  the  nature  of  the  matters  vomited  and 
the  physical  condition  of  the  abdomen.  The  usual 
tendency  is  towards  constipation,  although  there  are 
cases  marked  by  diarrhoea  or  by  constipation  alterna- 
ting with  diarrhoea.  The  tendency  to  faecal  vomiting 
is  about  the  same.  In  one  case  of  so-called  "  colloid 
cancer  "  of  the  loAver  ileum  there  was  complete  con- 
stipation for  fifty  days  before  death,  with  feculent 
vomiting  that  appeared  some  thirty  days  before  the 
termination  of  the  case.  The  vomiting,  even  after  it 
had  become  stercoraceous,  ceased  for  a  while  (for 
twelve  days),  and  on  recommencing  no  longer  pre- 
sented the  stercoraceous  character.! 

The  duration  of  the  symptoms  is  certainly  longer 
in  cases  of  cancerous  stricture  than  it  is  in  those  of 
simple  stricture.  It  would  be,  perhaps,  more  correct 
to  say  that  the  symptoms  appear  earlier  in  the  former 
than  in  the  latter  form  of  obstruction.  In  no  instance 
could  the  malady  have  been  said  to  pursue  a  subacute 
course.  In  the  least  chronic  case  the  symptoms  had 
lasted  for  at  least  four  and  a  half  weeks  before  death. 
In  several  instances  distinct  relief  attended  the 
administration  of  aperients. 

*  Lancet,  vol,  i.,  1873,  page  42. 

fDr.  Hilton  Fagge ;  Guy's  Hospital  Reports,  vol.  xiv.,  1869. 


29S  Intestinal  Obstruction.      tChap-  xiii. 

In  one  case  of  "  cancer  "  involving  the  lower  part 
of  the  ileum  there  were  severe  and  repeated  haemor- 
rhages from  the  anus."^  The  case  was  associated  with 
persistent  diarrhoea.  In  these  forms  of  stricture  there 
appears  to  be  more  pain  than  in  the  simple  forms,  and 
especially  is  there  more  frequently  a  fixed  pain,  which 
may  exist  in  addition  to  the  pain  that  is  paroxysmal. 

Emaciation  is  much  more  marked,  appears  earlier, 
and  ad^'ances  more  rapidly.  There  is  also,  throughout  the 
case,  a  more  distinct  impairment  of  the  general  health. 

In  three  out  of  the  ten  instances  of  cancer  of  the 
small  intestine  that  I  have  collected  the  new  growth 
formed  a  distinct  tumour  that  was  readily  felt  through 
the  abdominal  parietes. 

Diu'atiou  and  prognosis. — In  two  of  the 
cases  of  simple  stricture,  intestinal  symptoms^  as 
already  mentioned,  existed  for  not  more  than  eight 
days  before  death.  In  another  case  (that  of  Kceberle's) 
the  symptoms  of  stricture  had  existed  for  two  or  three 
years  before  the  patient  was  relieved  by  operation. 
Putting  aside  these  exceptional  instances,  I  find  that 
the  average  duration  of  the  remaining  thirteen  cases 
was  three  months.  By  the  duration  of  the  disease  is 
merely  meant  the  interval  of  time  between  the  first 
appearance  of  obstruction  symptoms  and  the  termina- 
tion of  the  case. 

Kceberle's  patient  i-ecovered  after  resection  of  the 
diseased  intestine.  The  cause  of  death  in  the  remain- 
ing cases  was  as  follows  :  Two  died  after  operation, 
eight  of  perforation,  and  five  of  exhaustion  attending 
upon  persistent  obstruction. 


"o^ 


was   five  months.     In  one  case  death  followed  upon 
operation,  in  two  cases  it  was  due  to  perforation,  in 
three  to  acute  peritonitis  independent  of  perforation, 
and  in  the  remaining  four  instances  to  exhaustion. 
♦Bull,  cle  la  Soc.  Anat.  de  Paris,  1875,  page  299. 


Chap,  xin.]        Stricture  :  Symptoms.  299 

The  prognosis  in  stricture  of  the  small  intestine 
is  absolutely  unfavourable  unless  the  case  be  relieved 
by  operation.  In  instances  of  malignant  stricture  it 
will  be  obvious  that  even  an  operation,  successful 
at  the  time,  can  only  lead  to  temporary  relief. 

Spontaneous  relief  to  the  obstructed  part  may  be 
given  by  ulceration  of  the  bowel  above  the  stricture. 
By  means  of  such  ulceration  this  part  of  the  intestine 
may  communicate  with  the  bowel  below  the  seat  of 
the  stenosis  and  through  this  communication  the  in- 
testinal contents  may  be  passed  along.  Although  I 
am  aware  of  no  actual  case  where  continued  relief 
was  obtained  by  these  means,  yet  many  cases  show 
that  it  is  quite  possible,  and  indeed  in  one  reported 
instance  of  stricture  of  the  ileo-csecal  valve  this 
method  of  spontaneous  cure  had  taken  place.  In 
this  instance  the  ileum  above  the  stricture  had  com- 
municated with  the  colon  below  it.'^ 

It  would  be  quite  possible  also  for  a  fsecal  fistula  to 
form  above  the  stenosed  part,  which,  by  a  communica- 
tion with  the  surface,  would  play  the  pai-t  of  an 
artificial  anus.  In  a  case  under  my  care  at  the 
London  Hospital  an  obstruction  existed  in  the  small 
intestine  due  to  a  matting  together  of  the  coils  of  the 
bowel.  The  mucous  membrane  had  become  the  seat 
of  tubercular  ulcers,  one  of  which  had  led  to  perfora- 
tion, and  subsequently  to  a  fsecal  fistula  discharging 
near  the  umbilicus.  Through  this  fistula  the  contents 
of  the  bowel  were  passed,  and  for  many  Aveeks  before 
deatli  no  fiscal  matter  was  passed  in  any  other  way 
than  through  this  abnormal  passage. 

STRICTURE    OF    THE    ILEO-C^CAL    VALVE. 

No  distinctive  symptoms  attend  stricture  of  this 
part.     They  are  practically  identical  with  those  asso- 
ciated with  stenosis  of  the  small  intestine.     Of  the 
*Patli.  Soc.  Trans.,  vol.  xxi.,  1870,  page  171. 


300  Intestinal  Obstruction.      [Chap.  xiii. 

eight  examples  I  have  collected,  two  patients  died  of 
causes  not  directly  connected  with  the  obstruction. 
In  the  remaining  cases  there  was,  among  other  symp- 
toms, vomiting  which  became  feculent  in  two  in- 
stances, remained  non-stercoraceous  in  three,  and  is  in- 
definitely described  in  one  example.  In  each  instance 
the  general  condition  of  the  bowels  was  that  of  chronic 
constipation.  In  no  case  was  any  tumour  detected. 
As  regards  the  duration  of  the  symptoms,  in  one  re- 
corded case  they  appear  to  have  existed  for  less  than  one 
month  before  death.  In  this  example  the  valve  was 
occluded  by  a  new  growth.  In  Dr.  Wickham  Legge's 
case  obstruction  symptoms  had  existed  at  intervals 
for  at  least  eleven  years.  It  is  supposed  that  the 
stricture  was  in  this  instance  congenital.  In  the  re- 
maining cases  the  average  duration  of  the  symptoms 
before  death  was  seven  months. 

Two  patients,  as  already  noted,  died  of  causes  not 
directly  connected  with  the  obstruction.  Of  the  rest, 
one  died  after  operation,  two  from  perforation,  while 
three  succumbed  to  the  effects  of  long-continued  ob- 
struction of  the  bowel. 

THE    LARGE    INTESTINE — SIMPLE   STRICTURE. 

The  symptoiiis  of  stenosis  of  this  part  have  a  con- 
siderable resemblance  to  tliose  depending  upon  stric- 
ture of  the  lesser  bowel.  In  many  instances  it  is 
difficult  and  even  impossible  to  precisely  differentiate 
simple  stricture  localised  in  these  two  segments  of  the 
intestine. 

The  most  conspicuous  symptom  consists  of  attacks 
of  paroxysmal  pain  that  appear  at  intervals.  These 
attacks  much  resemble  those  already  described  when 
speaking  of  the  lesser  bowel.  Thty  may  be  the  first 
indications  of  the  disease,  but  usually  appear  after 
some  such  intestinal  disturbance  as  chronic  constipa- 
tion, or  constij^ation  alternating  with  diarrhtca.     They 


Chap.  XIII.]        Stricture:  Sv3TPTonTS.  301 

depend,  no  doubt,  upon  some  temporary  obstruction  of 
the  stricture.  The  pain  is  usually  less  severe  than  is  the 
case  in  the  paroxysms  attending  stricture  of  the  small 
intestine.  There  is  also  less  vomiting  which  will  ap- 
pear later  in  the  attack,  will  be  comparatively  scanty, 
and  will  never  be  stercoraceous  unless  after  many 
days  of  absolute  constipation. 

The  interval  of  time  between  the  earlier  attacks 
is  often  considerable.  Thus  in  one  case  nine  months 
elapsed  between  the  first  and  second  attacks.  In 
other  instances  there  have  been  three  or  four  attacks 
a  year  for  some  years.  As  the  stricture  narrows  these 
occurrences  become  more  frequent  and  more  trouble- 
some. 

Unlike  the  strictures  of  the  small  intestine^ 
stenosis  of  the  colon  is  generally  unattended  by  symp- 
toms of  the  nature  of  indigestion.  There  is  usually 
no  connection  between  the  attacks  of  pain  and  the  in- 
gestion of  food.  Indeed,  in  only  one  of  the  recorded 
cases  have  I  found  this  connection.  The  case  in 
question  was  one  of  simple  stricture  at  the  hepatic 
flexure.  Attacks  of  pain  and  vomiting  came  on  some 
two  or  three  hours  after  nearly  every  meal,  so  that  the 
patient  at  last  became  almost  afraid  to  eat."^ 

The  attacks  in  cases  of  stenosis  of  the  lesser  boAvel 
are  commonly  relieved  by  the  administration  of  a 
purge.  In  cases,  however,  involving  the  colon  the 
opposite  obtains.  Aperients  are  apt  to  aggravate 
existing  symptoms,  a  circumstance  that  depends,  no 
doubt,  upon  the  more  solid  character  of  the  contents 
of  the  larger  bowel.  The  final  obstruction  is  usually 
preceded  by  many  attacks  of  paroxysmal  pain.  Be- 
tween these  attacks  the  patient  may  feel  fairly  well, 
although  he  is  usually  troubled  by  constipation,  or  by 
constipation  alternating  with  diarrhoea  and  with  much 
flatulence.  When  the  obstruction  becomes  absolute 
*  EuU.  de  la  Soc.  Anat.,  1870,  page  322. 


302  Intestinal  Obstruction.      [Chap.  xiii. 

the  character  of  the  pain  changes,  just  as  is  the  case 
in  the  small  intestine ;  it  ceases  to  be  distinctly  in- 
termittent and  becomes  more  continuous. 

The   prevailing   condition  of  the   bo^vels    is 

one  of  chronic  constipation,  that  is  now  and  then  as- 
sociated with  a  little  spurious  diarrhcea,  just  as  is  seen 
in  cases  of  stricture  of  the  rectum.  In  thirteen  cases 
of  simple  stricture  constipation  was  the  prevailing 
condition  in  eleven  instances.  In  the  remaining  two  ex- 
amples there  was  constipation  alternating  with  marked 
diarrhoea.  The  final  attack  is  characterised  by  abso- 
lute constipation.  Nothing  may  pass  the  rectum  for 
ten  or  twenty  days  before  death.  In  some  cases  the 
period  of  absolute  constipation  has  exceeded  these 
limits,  and  has  attained  a  duration  of  thirty"*  and 
even  of  forty  days,  f  During  the  earlier  attacks  there 
is  also  constipation. 

The  constipation  at  first  yields  to  aperients  or 
enemata,  but  in  time  becomes  more  and  more  obsti- 
nate. Enemata  usually  act  more  efficiently  than  pur- 
gative medicines.  It  has  been  shown  that  in  some 
cases  water  can  be  injected  through  the  stricture  from 
below,  but  not  from  above. 

Toniiting^  is  even  less  marked  in  stenosis  of  the 
colon  than  in  that  of  the  small  intestine.  In  the 
earlier  attacks  it  may  be  entirely  absent,  or  appear 
late  and  be  very  scanty.  In  the  more  serious  attacks 
vomiting  is  more  frequent,  and  in  the  final  attack  it  is 
constant.  It  is  seldom  a  distressing  symptom  and 
often  fluctuates  in  severity,  being  sometimes  absent 
for  days  even  during  the  final  obstructive  attack.  It 
is  rarely  feculent  except  during  the  obstruction  that 
immediately  precedes  death.  Even  in  such  a  circum- 
stance the  cases  of  stercoraceous  vomiting  are  to  those 
of  non-feculent  vomiting  as  five  to  seven.     Feculent 

*  Dr.  Coupland  ;  Path.  Soc.  Trans. ,  vol.  xii. ,  page  94. 
■\  Lancet,  vol.  ii.,  1869,  page  80. 


Chap.  XIII.]        Stricture  :  Symptoms.  303 

vomiting  depends  more  upon  the  duration  and  com- 
pleteness of  the  occlusion  than  upon  its  situation  in 
the  colon.  There  are,  however,  some  striking  excep- 
tions to  this.  Thus,  in  the  two  cases  above  alluded  to, 
where  the  duration  of  complete  constipation  w^as 
respectively  thirty  and  forty-six  days,  the  vomiting- 
was  not  severe  and  never  became  feculent. 

In  another  case  the  ejected  matters  did  not  become 
stercoraceous  until  the  fourteenth  day  of  absolute 
constipation,  the  patient  dying  about  the  sixteenth 
day. 

Sometimes  the  vomiting  appears  at  fairly  regular 
intervals,  as  in  one^  case  of  stricture  of  the  sigmoid 
flexure,  where  the  patient  vomited  every  half  hour 
with  some  regularity. 

Among  the  more  special  symptoms  may  be  noticed 
the  occurrence  of  tenesiniis.  This  is  especially  apt  to 
occur  in  cases  of  stricture  low  down  in  the  colon,  and 
particularly  in  cases  associated  with  diarrhoea.  It  is 
more  marked  in  the  early  than  in  the  later  stages  of 
the  disease,  and  is,  I  think,  not  present  in  more  than 
one-third  of  the  cases. 

In  several  instances  of  stricture  in  the  sigmoid 
flexure  the  motions  passed  have  been  distinctly 
flattened  or  otherwise  altered  in  shape.  When  the 
stricture  is  in  a  higher  part  of  the  colon  the  faecal 
matter  passed  through  the  stenosed  part  becomes  re- 
modelled in  the  lower  portions  of  the  bowel  as  it 
passes  towards  the  rectum. 

In  one  case  the  patient  was  for  a  while  troubled 
with  stranguary. 

The  general  condition  of  the  sufferer  in  these 
cases  may  be  expressed  in  the  same  words  that  have 
been  applied  to  the  cases  of  those  afflicted  with  stric- 
ture of  the  lesser  intestine. 

The  abdominal  walls  remain  flaccid  unless  some  peri- 
tonitis has  developed.     There  is  but  little  meteorism 


304  Intestinal  Obstruction.      [Chap.  xiii. 

so  long  as  the  bowels  act,  and  in  cases  associated 
with  diarrhoea  the  parietes  may  be  retracted.  As  the 
obstruction  becomes  more  complete  the  abdomen  be- 
comes more  and  more  distended,  and  in  fatal  cases 
there  may  be  a  considerable  enlargement  of  the  belly 
by  the  time  that  death  occurs.  Yery  often  the  out- 
line of  the  colon  distended  with  fsecal  matter  is  very 
evident,  and  in  any  case  the  distension  will  be  most 
marked  in  those  parts  of  the  abdomen  that  are  occu- 
pied by  the  large  intestine.  The  outline  of  the  colon, 
moreover,  may  be  indicated  by  some  dullness  on 
percussion,  while  the  region  of  the  small  intestine  re- 
mains tympanitic. 

Often  large  ffecal  masses  can  be  felt  in  the  bowel 
above  the  obstruction,  masses  so  prominent  as  to 
sometimes  form  very  distinct  tumours,  the  nature  of 
which  has  not  ahvays  been  accurately  diagnosed. 

Great  assistance  in  the  diagnosis  of  the  seat  of  the 
stenosis  is  afforded  by  the  auscultation  of  the  ab- 
domen during  the  administration  of  enemata,  and  by 
these  means  it  is  possible  in  some  cases  to  arrive  at  a 
very  correct  knowledge  of  the  site  of  the  trouble. 

A  stricture  in  the  sigmoid  flexure  or  even  in  the 
lower  part  of  the  descending  colon  may  be  felt  by  the 
finger  when  the  entire  hand  is  introduced  into  the 
rectum.  Dr.  Sands,  however,  reports  a  case  where  a 
stricture  situated  within  fifteen  inches  of  the  anus  was 
not  recognised,  although  the  entire  hand  had  been  in- 
troduced so  far  as  the  sigmoid  flexure.* 

CANCEROUS    STRICTURE. 

In  the  stenoses  of  the  colon  described  under  this 
heading  the  syiiiptoiiis  that  arise  so  closely  resemble 
those  appertaining  to  simple  stricture  that  little  more 
is  required  than  to  point  out  cei  tain  matters  of  difier- 
ence. 

*  Nzw  Ywk  Med.  Journ.^  vol.  xix.,  1874,  page  622. 


Chap.  X I  n . ]  StR I C TURK  .*     SyMP TOMS.  3 05 

The  duration  of  the  symptoms  is  a  little  longer 
in  cases  of  so-called  cancer  than  it  is  in  the  cica- 
tricial stenoses.  Duration  of  symptoms,  liowever, 
need  not  correspond  with  duration  of  disease,  and  of 
these  cancerous  obstructions  it  would  be  more  correct 
to  say  that  they  lead  to  the  production  of  evidences 
of  occlusion  at  an  earlier  period  tlian  do  the  other 
species  of  stricture. 

In  some  instances  the  patient  has  had  symptoms 
of  narrowing  of  the  intestine  for  twelve  and  even  for 
twenty-four  months  previous  to  deatli,  and  the  autopsy 
has  then  revealed  a  stricture  of  a  "cancerous" 
character.  I  think  that  in  these  cases  the  "  cancer  " 
may  either  have  been  an  innocent  growth  or  that  an 
epithelioma  may  have  developed  upon  the  tissue  of  a 
cicatrix  that  had  caused  some  symptoms  for  months. 

The  general  course  of  the  malady  resembles  that 
of  stricture  generally.  There  would  ajjpear  to  be 
more  pain  than  is  common  in  non-cancerous  cases,  and 
it  is  usually  of  a  more  fixed  character. 

In  one  case  the  malady  appears  to  have  com- 
menced with  severe  pain  in  the  back  that  lasted  for 
two  or  three  months.  The  stricture  was,  in  this  in- 
stance, in  the  sigmoid  flexure."^  The  pain  is  often 
worse  just  before  an  action  of  the  bowels,  a  circum- 
stance that  is  especially  to  be  noticed  in  stricture  low 
down  in  the  colon.  It  is  also  apt  to  be  increased  by 
the  use  of  aperients. 

The  general  state  of  the  bowels  is  a  little  different 
from  that  usual  in  the  i)revious  class  of  stricture. 
The  malady  would  appear  to  begin  often  with 
diarrhosa,  followed  by  diai'rhcea  alternating  with  con- 
stipation and  then  ending  in  a  constipation  that  is 
more  or  less  obstinate.  From  an  analysis  of  twenty- 
eight  cases  it  appears  that  in  fourteen  cases  consti})a- 
tion  was  the  prominent  state  of  the  bowels,  in  eleven 

*  Lancet.,  vol.  i.,  187n,  page  3G9. 
U— 13 


3o6  InT'Estinal  Obstruction.      ichap.  xiii. 

instances  there  was  an  alternation  of  constipation  with 
marked  diarrhoea,  while  in  three  cases  diarrhoea  was 
the  predominant  feature. 

The  cases  of  diarrhoea  and  of  constipation  alter- 
nating with  diarrhoea  mostly  concerned  the  higher 
part  of  the  colon,  while  nearly  all  the  instances  of 
obstruction  in  the  sigmoid  flexure  were  attended  by 
constipation  as  the  most  pronounced  condition. 

The  fatal  termination  is  usually  preceded  by  a 
period  of  absolute  constipation,  although  this  circum- 
stance is  not  quite  so  common  as  it  is  in  cases  of 
cicatricial  stricture.  The  duration  of  this  fatal  ob- 
struction varies  from  a  few  days  to  two  or  three 
weeks.  In  one  patient,  whose  case  is  recorded  by  Mr. 
Cooper  Forster,  no  motion  was  passed  for  eighty-eight 
days  before  death."*  Absolute  constipation  for  thirty 
days  is  not  very  uncommon. 

When  the  obstruction  involves  the  sigmoid 
flexure  the  motions,  when  solid,  are  often  flattened 
or  much  narrowed,  or  in  other  ways  altered  in  out- 
line. 

A  bloody  discharge  from  the  anus  is  met  with  in 
about  15  per  cent,  of  all  the  cases,  and  is  mostly  ob- 
served in  connection  with  strictures  of  the  sigmoid 
flexure. 

Tciicsiiius  is  more  common  in  this  form  than  in 
the  previous  one.  It  is  the  more  frequent  the  nearer 
the  occlusion  is  to  the  anus,  and  is  most  usually  met 
with  in  cases  associated  with  diarrhcea  or  with  con- 
stipation alternating  with  diarrhoea. 

Vomiting'  nearly  always  appears  at  some  tiuie 
during  the  progress  of  tlie  malady.  It  usually  sets  in 
late,  is  very  irregular  in  its  occurrence,  is  scanty,  and 
seldom  becomes  a  very  distressing  symptom. 

In  one  case  reported  by  Dr.   Bristowe  vomiting 
occurred  during  the  early   but  not  during  the  final 
*  Guy's  Hosp.  Reports,  vol.  xiv. ,  18G0,  page  377. 


Chap.  XIII.]         Stricture  :   Symptoms.  307 

attack,  in  spite  of  there  being  pronounced  con- 
stipation.* 

In  not  a  few  instances  the  vomiting  was  quite  in- 
significant in  amount  and  the  cause  of  comparatively- 
little  trouble  to  the  patient.  Out  of  twenty  cases,  the 
vomited  matters  became  stercoraceous  in  eight  in- 
stances and  remained  throughout  non-feculent  in 
twelve.  Most  of  the  instances  of  feculent  vomiting 
occurred  in  the  final  attack  and  were  associated  with 
constipation.  Among  the  cases  of  feculent  vomiting 
were  the  greater  number  of  the  cases  of  stricture  high 
up  in  the  colon.  In  the  case  already  alluded  to,  in 
which  there  was  absolute  constipation  for  eighty-eight 
days,  the  vomited  matters  never  became  stercoraceous. 

The  general  condition  of  the  patient  is  similar  to 
that  described  in  speaking  of  cancerous  stricture  of  the 
lesser  bowel,  with  the  exception,  perhaps,  that  emacia- 
tion proceeds  less  rapidly. 

Nothing  especial  remains  to  be  noted  as  to  the 
jDhysical  condition  of  the  abdoDien.  The  coils  of 
intestine  are  usually  distinctly  visible,  especially 
during  the  occurrence  of  paroxysms  of  pain,  just  as  is 
the  case  in  the  simple  strictures. 

From  an  examination  of  the  recorded  cases  it  would 
appear  that  an  abdominal  tumour  has  not  been  ob- 
served in  more  than  40  per  cent,  of  all  the  cases, 
understanding  the  term  "  tumour "  to  refer  to  a 
mass  formed  by  the  new  growth  itself.  In  some  of 
these  recorded  instances  the  abdomen  was  not  es- 
pecially examined  for  evidences  of  a  tumour.  In 
others,  a  tumour  that  might  have  been  detected  in  a 
flaccid  abdomen  was  concealed  by  the  meteoristic  con- 
dition of  the  1)ellv.  Then  ao^ain  a  new  growth 
situated  in  the  hepatic  or  splenic  flexure  may  attain 
considerable  dimensions  before  it  becomes  largo 
enough  to  be  evident  upon  the  surface.  Moreover  the 
*  rath.  Soc.  Trans.,  vol.  xxiii. ,  page  119. 


3o8  Intestinal  Obstruction.       [Chap.  xiii. 

epitheliomatous  stricture  very  commonly  leads  to  no 
tumour  at  all  in  the  sense  of  a  mass  that  projects 
beyond  the  normal  lines  of  the  intestine. 

Duratiou  and  progruosis. — The  average  dura- 
tion of  the  symptoms  in  simple  stricture  of  the  colon 
is  five  months  and  in  the  so-called  cancerous  stricture 
six  months.  In  a  few  instances  the  earlier  symptoms 
have  been  so  insignificant  that  little  has  been  noticed 
in  the  record  save  the  final  attacks,  and  such  cases 
would  appear  to  show  examples  of  stricture  fatal  in 
sixteen  days  or  even  less.  The  fallacy  in  such  cases 
is  obvious.  In  thirteen  cases  of  cicatricial  stenosis 
the  causes  of  death  were  as  follows  :  operation  2, 
perforation  4,  peritonitis  independent  of  perforation  2, 
and  exhaustion  from  the  effects  of  persisting  obstruc- 
tion 5. 

Out  of  a  total  of  twenty-eight  instances  of 
"  cancer  "  of  the  colon  four  patients  recovered  after 
operation,  six  died  within  a  short  j^eriod  of  operation, 
five  deaths  were  due  to  perforation,  and  four  to  peri- 
tonitis apart  from  perforation,  while  nine  died  from 
exhaustion  incident  to  persistent  obstruction  and  to 
the  constitutional  effects  of  the  neoplasm. 

The  prognosis  in  all  forms  of  stricture  of  the 
colon  is  entirely  bad  provided  that  the  stenosed  pai*t 
be  narrow  enough  to  offer  a  definite  obstruction. 

The  only  prospect  of  spontaneous  relief  is  afforded 
by  ulceration  of  the  gut  above  the  stricture  and  the 
subsequent  formation  of  a  fistula  which  can  act  the 
part  of  a  praeternatural  anus.  Thus  a  faecal  abscess 
may  form  in  the  subserous  connective  tissue  and  be 
evacuated  externally  either  by  nature  or  art ;  *  or  the 
intestine  above  the  obstruction  may  communicate 
with  the  gut  below  it,  as  is  possible  in  a  case  of  stric- 
ture in  the  lower  part  of  the  sigmoid  flexure,  where 
the  flexure  is  much  distended  and  freely  movable  ; 
*Dr.  Dickinson,  case  ;  Patli.  Soc.  Trans.,  vol.  xxiii.,  page  161. 


Chap.  XIV.]       Tumours  of  the  Bowel.  309 

or,  lastly,  the  fistulous  opening  may  discharge  itself 
through  the  wall  of  the  bladder  or  vagina.^  Such 
attempts  at  spontaneous  relief  are  efficacious  only  for 
a  little  while  and  the  changes  that  attend  the  forma- 
tion of  the  fistida  usually  lead  to  such  further 
destructive  Drocesses  as  are  incompatible  with  life. 


CHAPTER    XIY. 

OBSTRUCTION    OF    THE    INTESTINE   BY    NEOPLASMS. 

In  addition  to  the  malignant  growths  from  the  bowel 
to  which  attention  has  been  already  directed,  notice 
must  be  taken  of  certain  benign  neoplasms  that  some- 
times lead  to  obstruction.  In  the  production  of  such 
stenoses  it  is  possible  to  recognise  many  different 
forms  of  innocent  tumour. 

1.  Adenomata. — These  grow  from  the  mucous 
membrane  and  appear  to  have  their  origin  in  the 
follicles  of  Lieberkiihn.  They  present  on  section  a 
number  of  tubes,  passages,  and  sj^aces,  all  lined  Avith 
columnar  epithelium  and  su^^ported  by  connective 
tissue  that  may  vary  in  structure  from  a  lax  myxoma- 
tous meshwork  to  a  substantial  fibrous  substance.  It 
is  upon  the  character  of  this  supporting  tissue  that 
the  physical  characters  of  the  growth  in  some  part 
depend,  the  laxer  tissues  forming  soft,  and  the 
denser  structure  firm,  polypoid  masses.  The  mode  of 
origin  of  these  growths  has  been  very  elaborately 
described  by  Mr.  Harrison  Cripps,  in  regard,  at  least, 
to  their  appearance  in  the  rectum.  It  would  appear 
that  the  line  of  demarcation  between  them  and  the 
cylindrical  epitheliomata  is  very  faint,  and  that  one 

*Mr.  Simon,  case;  Path.  Soc.  Trans.,  vol.  i.,  page  264. 


310  lyTESTINAL    OBSTRUCTION.  [Chap.  XIV. 

species  of  growth  may  shade  off,  as  it  were,  into  the 
other.  The  majority  of  these  growths  assume  the 
aspects  of  a  projecting  tumour  and  have  been  described 
under  the  names  of  papilloma,  fibrous,  or  mucous 
papilloma,  benign  villous  polyp  and  the  like.  Some- 
times the  neoplasm  spreads  laterally  under  the  im- 
mediate surface  of  the  mucous  membrane,  producing 
the  groM'th  known  as  a  "  flat  adenoma." 

These  adenomata  are  most  frequently  met  with  in 
the  rectum  and  colon  and  form  the  commonest  variety 
of  l)enign  growth.  They  frequently  occur  in  children, 
and  are  perhaps  more  often  multiple  than  single.* 

2.  Fibromata. — These  are  said  to  arise  from 
the  submucous  tissue.  A  large  number  of  growths 
are  described  as  "  fibrous  polypi,"  but  reliable  micro- 
scopic evidence  is  wanting  to  shov,-  that  even  the  ma- 
jority of  these  are  composed  of  fibrous  tissue.  It  is 
probable  that  they  belong  rather  to  the  next  variety. 

3.  Fibro-iiiyomata. — Several  examples  of  this 
kind  of  benign  growth  have  been  placed  on  record, 
the  nature  of  the  tumour  having  been  verified  by 
microscopical  examination.  They  arise  from  the  sub- 
mucous and  muscular  coat,  and  have  an  ai-rangement 
of  j^arts  like  that  seen  in  simple  fibro-myomata  of  the 
uterus.  Those  having  origin  from  the  submucous 
coat  spring,  no  doubt,  from  the  mucosa  musculai-is.f 

4.  Lipoiitata. — These  growths  spring  from  the 
submucous  layer,  take  a  polypoid  form,  are  often 
multiple  but  seldom  of  great  size.| 

5.  Among  the  still  rarer  growths  may  be  men- 
tioned aiigioiiiata,  examples  of  which  have  been 
described  by  authors.  Some  of  these  are  probably  in 
reality  very  vascular  fibro-myomata. 

*  See  a  remarkable  case  reported  in  the  Brit.  Med.  Journ., 
March  1,  1884,  page  410. 

t  See  speciin«n  in  Lond.  Hosp.  Museum,  No.  Ad.  41. 
X  For  specimen  see  Lond.  Hosp.  Museum,  No.  Ae.  45. 


Chap.  XIV.J  Ti'AWURS    OF    TJ/F.    BOWFL.  31I 

Kokitansky  has  described  cases  where  miiltilocular 
cysts  filled  with  serum  were  found  partly  embedded 
in  the  intestinal  wall.  It  may  be  that  these  were 
cystic  adenomata. 

Considered  collectively,  benign  tumours  of  the 
intestine  are  usually  met  with  in  the  form  of  polypi. 
As  such  they  may  have  very  distinct  pedicles.  In  a 
case  of  Sir  Prescott  Ilewett's  the  pedicle  was  the  size  of 
the  finger  and  one  and  a  half  inches  in  length.  In 
shape  they  are  round,  oval,  or  pear-shaped.  In  size 
they  vary  from  the  dimensions  of  a  pea  to  that  of  a 
small  orange  or  a  pear.  They  are  usually  covered  by 
normal  mucous  membrane,  which  may,  however,  be  in 
a  condition  of  ulceration.  As  regards  -their  place  of 
origin,  the  great  majority,  probably  not  less  than 
80  per  cent.,  are  met  with  in  the  rectum.  Next  in 
frequency  comes  the  ileum  and  then  the  colon.  They 
are  rare  in  the  jejunum  and  still  rarer  in  the  duodenum. 
As  regards  the  small  intestine,  the  favourite  site  is  the 
lower  extremity  of  the  ileum. 

The  growth  is  usually  attached  to  the  convex 
border  of  the  gut,  or  at  least  away  from  the  mesen- 
teric border.  It  is  not  uncommon  for  tlie  polyp  to 
drag  in  that  part  of  the  intestinal  wall  to  which  it  is 
attached  and  so  produce  a  depression  or  umbilicus 
upon  the  surface  of  the  gut.  In  one  case,  where  an 
intussusception  had  been  produced,  this  depression 
was  sufficiently  deep  and  definite  to  admit  the  tip  of 
the  little  finger."^ 

Benign  polypi  are  often  very  numerous.  Allusion 
has  already  been  made  to  an  instance  where  no  less 
than  thirty  of  such  growths  were  found  in  the  lower 
ileum.  The  occurrence  of  three,  four,  or  five  polypi  in 
the  same  division  of  the  bowel  is  quite  common. 

Benign  growths  of  the  intestine  may  give  rise  to 
no  symptoms  during  life  and  may  even  attain  large 
*M.  Fcinot;  Bull,  de  la  Soc.  Anat.,  1SG3,  j^age  29G. 


312  InTES  TINA  L    ObS  TR  UC TION.  [Chap.  XIV. 

size  and  become  quite  numerous  without  aflfording 
any  evidence  of  their  existence,  Tlius,  in  two  cases 
of  very  large  polypi  of  the  ileum,  reported  by  Sir 
Prescott  Hewett,  no  symptoms  aj)pear  to  have  been 
induced  until  an  intussusception  arose.  One  of  these 
growths  was  as  large  as  a  pear,  the  other  measured 
two  and  three-quarter  inches  by  one  and  a  half 
inches."^  These  polypi  most  usually  cause  symptoms 
when  in  the  rectum,  producing  tenesmus,  bleeding 
from  the  bowel,  difficult  defsecation  and  a  sense  of  a 
foreign  substance  in  the  gut.  The  same  symptoms  in 
a  less  marked  degi'ee  may  attend  gi'owths  arising  from 
the  sigmoid  flexure. 

In  other  parts  of  the  intestine  the  polyp  usually 
causes  obstruction,  if  it  occlude  the  gut  at  all,  by 
inducing  an  invagination.  This  is  particularly  the 
case  with  such  as  grow  from  the  ileo-csecal  valve  and 
from  the  terminal  part  of  the  ileum.  Benign  tumours 
have  also  produced  intussusceptions  in  other  parts  of 
the  bowel,  in  the  rectum,  in  the  sigmoid  flexure,  and 
in  all  parts  of  the  colon. 

When  the  mass  is  of  large  size,  or  when  the 
growths  are  multiple,  symptoms  of  obstruction  may 
be  produced  that  more  or  less  closely  resemble  the 
symptoms  of  stricture,  save  tliat  they  are  usually  more 
chronic  and  for  a  while  at  least  less  marked.  Some 
of  the  most  inarked  examples  of  this  form  of  obstruc- 
tion have  been  met  with  in  connection  with  growths 
springing  from  the  margin  of  the  ileo-C£ecal  valve. 

So  far  as  I  am  aware,  it  would  be  impossible  to 
diagnose  cases  of  obstruction  due  to  simple  neoplasms 
from  cases  of  stricture.  I  can  find  no  instance 
recorded  where  the  growth  was  felt  through  the 
j)arietes  during  life,  except  perhaps  when  associated 
with  an  invagination. 

In  one  or  two  instances  these  polypi  have  excited 
*rath.  Soc.  Trans.,  vol.  i.,  page  9.5. 


Chap.  XTV.]       Tumours  of  the  Bowel.  313 

some  chronic  peritonitis  in  the  wall  of  the  bowel  from 
which  they  have  taken  origin. 

In  a  few  cases  the  polyp  has  separated  from  its 
attachment  and  has  been  passed  per  annm.  This 
mostly  occurs  in  connection  with  such  gi^owths  as 
spring  from  the  rectum  or  sigmoid  flexure ;  although 
I  am  disposed  to  believe  tliat  some  reported  cases 
where  strange  fleshy  masses  have  ])een  passed  with 
motions  might  have  been  examples  of  the  spon- 
taneous removal  of  a  x>olyp.  An  excellent  example 
of  separation  of  such  a  tumour  from  the  sigmoid 
flexure  or  rectum  is  reported  by  M.  Afezou.  It 
concerned  an  old  woman,  aged  eighty-three, 
who  had  been  troubled  for  a  number  of  years 
with  indigestion,  attacks  of  colic  and  constipa- 
tion alternating  with  diarrha3a.  At  last  the  constipa- 
tion became  so  pronounced  that  no  relief  to  the  bowel 
could  be  obtained  except  by  enemata.  One  day  after 
an  examination  of  the  bowel  a  soft  mass  was  passed. 
It  proved  to  be  a  lij)omatous  polyp.  All  the  patient's 
intestinal  troubles  at  once  ceased  and  the  bowels 
became  regular  again.  "^^ 

Sarcomatous  tumours  have  been  met  with  in 
the  intestine  both  as  primary  and  as  secondary 
growths.  Tliey  are  usually  of  the  spindle-celled 
variety,  and  are,  according  to  Leichtenstern,  very 
seldom  of  the  small-celled  kind.  They  very  rarely 
indeed  appear  as  polypi,  but  rather  tend  to  spread 
around  the  bowel,  and  then  probably  produce  one 
form  of  what  is  vaguely  known  as  a  "  cancerous  " 
stricture.     To  this  allusion  has  been  already  made. 

In  a  specimen  in  the  London  Hospital  Museum  is 
shown  a  tumour  that  is  apparently  a  primary  melanotic 
growth  arising  from  the  ileum.  So  far  as  I  can 
ascertain  such  tumours  are  extremely  rare.  The  case 
from  which  the  specimen  is  taken  is  peculiar.      The 

*P>uU.  (le  la  Soc.  Anat.,,  1875,  page  195. 


314  Intestinal  Obstruction.       [Chnp.  xiv. 

patient,  a  woman,  died  of  an  intussusception  at  the 
apex  of  which  the  gTo^\i:h  was  found.  She  had  a  small 
lump  in  her  groin  which  was  supposed  to  be  a  stran- 
gulated hernia.  It  was  cut  down  upon  and  found  to 
be  a  gland  affected  with  melanosis."^ 

Several  examples  of  lympho-sarcoma  of  the  intes- 
tine have  been  recorded  in  connection  with  Hodgkin's 
disease.  The  neoplasm  in  these  cases  appears  in  the 
adenoid  tissue  of  the  gut  and  in  Peyer's  patches, 
and  may  attain  considerable  dimensions.  At  many 
parts  the  whole  calibre  of  the  gut  has  been  surrounded 
by  an  extensive  morbid  growth,  while  in  other  places 
only  poi'tions  of  the  intestinal  wall  have  been  in- 
vaded, f  The  most  remarkable  feature  in  these  cases 
is,  that  so  far  as  recorded  examples  at  present  show, 
no  obstruction  is  usually  produced.  Indeed,  the  sub- 
jects of  the  disease  appear  to  have  had  either  no 
special  abdominal  symptoms  or  else  a  more  or  less  pro- 
nounced diarrhoea.  Dr.  Carrington  has  recently  re- 
ported a  case  where  a  lympho-sarcomatous  mass 
weighing  no  less  than  half  a  pound  occupied  the 
caecum,  and  yet  no  symjDtoms  of  obstruction  were  pro- 
duced, nor  indeed  does  special  attention  appear  to 
have  been  directed  to  the  abdomen  during  life.  \ 

*  Loud.  Hosp.  Museum,  No.  Ad.  48. 

t  See  case  by  Dr.  Moxou ;  Path.  Soc.  Trans. ,  vol.  xxiv. ,  1873, 
page  101.     And  another  by  Dr.  Murchison  ;  ibid.,  1870,  page  194. 

Ij:  Brit.  Med.  Journ.,  vol.  ii.,  1883,  page  773.  See  also  observa- 
tions by  Birch-Hirschfeld  ;  Ziern.ssen's  Cyclopedia  of  Medicine, 
vol.  xvi.,  jjage  837. 


3^5 


CHAPTER  XV. 

COMPRESSION    OF    THE    INTESTINE    BY    TUMOURS,    ETC., 
EXTERNAL    TO    THE    BOWEL. 

Tumours  of  various  kinds  and  even  displaced  viscera 
may  press  upon  some  part  of  the  intestine  and  cause 
thereby  an  occlusion  of  its  lumen. 

In  the  majority  of  the  cases  this  compression  has 
been  effected  by  a  tumour  having  origin  in  the  pelvis. 

Thus  the  bowel  may  be  compressed  by  a  retro- 
verted  or  retroflexed  uterus,  especially  when  enlarged 
by  pregnancy,"^  or  by  maglignant  or  other  tumours 
growing  from  the  uterus,!  or  by  ovarian  tumours  of 
any  kind.^  The  last-named  variety  of  growth  is  a 
frequent  cause  of  obstruction  by  compression.  Leich- 
tenstern  has  found  instances  of  compression  by  a  large 
vesical  calculus.  Mr.  Pye  gives  an  example  of  com- 
pression due  to  a  large  abscess  situated  between  the 
rectum  and  the  uterus.  §  Dr.  Hall  Davis  has  reported 
a  very  interesting  case  in  which  the  c£ecum  was  oc- 
cluded by  the  pressur  )  of  a  tumour  due  to  tubal  preg- 
nancy of  the  right  side,  ||  Among  other  causes  of 
pressure  upon  tlie  gut  may  be  mentioned  subperi- 
toneal tumours,  tumours  of  the  mesentery  or  omentum, 
various  tumours  of  the  kidney,  psoas  abscesses  and 
abscesses  about  the  ciecum,^  hydatid  cysts, '^"'^  enlarged 

*  Journ.  de  Med.  de  Chir. ,  etc.     Bruxelles,  1867. 
t  Mr.  Gay  ;  Path.  Soc.  Trans.,  vol.  iii.,  imge  108. 
X  Le  Dentu ;  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1879, 
page  601.     Mr.  Heath  ;  Path.  Soc.  Trans.,  vol.  xvi.,  page  197.    M. 
Verneuil;  Bull,  de  la  Soc.  Anat.,  1870,  page  411. 
§  Brit.  Med.  Journ.,  vol.  ii.,  1882,  page  11.52. 
II  Path.  Soc.  Trans,,  vol.  iv.,  page  230. 
If  Cases  quoted  by  Leichtenstern,  loc.  cit.,  page  573. 
**  Path.  Soc.  Trans. ,  vol.  v. ,  page  302. 


3t6  Intestinal  Obstruction.        [Chap.  xv. 

spleens.*  The  duodenum  especially  may  be  com- 
pressed by  tumours  growing  from  the  pancreas,!  by 
growths  arising  from  the  liver  and  by  masses  of  enlarged 
glands  about  the  portal  vein.  Dr.  Baimbrigge  reports 
a  case  of  obstruction  of  the  gut  brought  about  by 
pressure  indirectly  exercised  by  a  disj)laced  supple- 
mentary spleen,!  ^^^  ^^-  Nervier  quotes  an  instance 
where  a  hypertrophied  spleen  had  dragged  upon  the 
pancreas  and  had  displaced  it  so  that  it  had  compressed 
some  coils  of  intestine  that  had  found  their  way  be- 
neath it.  §  Ptollet  !|  gives  an  instance  of  compression 
by  the  pedicle  of  a  movable  kidney,  and  lastly  cases 
have  been  reported  where  a  piece  of  intestine  has  been 
engaged  and  compressed  between  the  ribs  and  the 
convexity  of  the  liver.  ^ 

With  reo^ard  to  the  segment  of  the  intestine  in- 
volved  in  these  cases,  the  rectum,  as  it  may  be 
supposed,  is  tlie  part  that  most  frequently  suffers. 
This  is  owing  to  the  preponderance  in  the  pehds  of 
tumours  capable  of  exercising  this  particular  com- 
pression. The  rectum,  moreover,  is  fixed  and  lies 
against  the  solid  wall  of  the  pelvis.  The  parts  that 
are  involved  next  in  frequency  after  the  rectum  are 
the  sigmoid  flexure  and  the  lower  ileum.  It  will  be 
seen  that  the  sigmoid  flexure  could  readily  be  com- 
pressed by  a  pelvic  tumour,  and  that  the  coils  of 
small  intestine  that  most  constantly  occupy  the 
pelvis  belong  to  the  lower  ileum.  I  have  collected 
twenty-two  examples  of  this  form  of  compression  of 
the  bowel,  which  may  be  thus  divided  with  regard  to 
the  matter  of  site.  Rectum  10,  colon  6,  caecum 
1,     small    intestine     5.        Leichtenstern     gives    the 

*  Case  quoted  by  Duchaussoy. 

t  Mr.  Nathan  ;  Med.  Times  and  Gazette,  vol.  ii.,  1870,  page  238. 

X  London  Med.  Gazette,  1846. 

§  De  rOcclusion  Intestinale,  page  47.     Liege,  1871 

II  Path.  u.  Therp.  d.  bewegl  Niere,  1866. 

If  Cases  by  Lavater  and  Kellenberg,  quoted  by  Leichtenstern. 


Chap.  XV.]     Compression  Of  the  Bowel.  317 

following  table  as  a  result  of  the  examination  of  a 
large  number  of  cases  collected  by  himself. 


Compression 

of  the  rectum,  in      .         . 

60 

per  cent. 

)i 

sigmoid  flcxui'e  and  de- 

scending colon,  in 

12 

}> 

lower  ileum,  in 

10 

)) 

duodenum,  in 

7 

)> 

ascending  colon,  in 

G 

5) 

middle  ileum,  in     . 

4 

>> 

transverse  colon,  in 

1 

It  will  be  seen  that  the  more  fixed  parts  of  the 
bowel  suffer  the  most,  and  that  the  more  mobile  parts, 
such  as  the  jejunum  and  transverse  colon,  are  prac- 
tically exempt  from  this  form  of  obstruction. 

In  all  the  instances  that  I  have  collected  the 
patients  were  adults. 

The  symptoms  of  obstruction  that  aiise  in  these 
cases  show  considerable  variety.  In  no  less  than 
twelve  out  of  the  twenty-two  examples  above  alluded 
to  the  compression  led  to  acute  obstruction,  the 
patient  dying  after  symptoms  the  duration  of  which 
varied  from  two  to  nine  days. 

In  two  instances  the  symptoms  were  subacute,  the 
duration  being  in  each  case  eighteen  days.  In  the 
remaining  eight  examples  the  obstruction  produced 
was  of  a  decidedly  chronic  character. 

The  acute  cases  depend  upon  sudden  comjiression 
of  the  gut  due  to  abrupt  change  of  position  in  the 
tumour  or  in  some  abnormally  ari-anged  viscus,  such 
as  an  unduly  movable  spleen  or  kidney.  Or  they 
may  be  due  to  kinking  of  the  intestine  or  to  abrupt 
bending  of  the  more  mobile  part  of  the  bowel  above 
that  fixed  by  the  tumour  or  to  the  engagement  of  a 
loop  of  intestine  beneath  the  mass  or  between  it  and 
the  pelvic  or  abdominal  walls.  The  acuteness  of  the 
case  appears  to  have  nothing  to  do  with  the  segment 
of  the  bowel  invohed,  but  to  depend  solely  upon  the 


3i8  Intestinal  Obstruction.        tchap. xv. 

abruptness  of  the  occlusion.  Many  of  the  more 
rapidly  fatal  cases,  cases  ending  in  death  on  the 
fourth,  sixth,  or  seventh  day,  have  depended  upon 
sudden  occlusion  of  the  rectum  or  of  the  lower  part  of 
the  colon.  The  case  alluded  to  above  as  fatal  in 
forty-eight  hours  was  Dr.  Baimbrigge's  case  of  com- 
pression by  a  displaced  spleen.  The  part  of  intestine 
involved  was  the  colon. 

The  symptoms  that  appear  in  these  cases  are 
simply  those  of  acute  obstruction.  There  is  less  pain 
and  less  collapse  than  in  instances  of  strangulation  by 
bands,  and  the  whole  progress  of  the  malady  is  less 
violent ;  but  the  points  of  difference  are  not 
sufficiently  accentuated  to  render  a  diagnosis  certain. 
In  many  instances  the  tumour  has  been  felt  and  the 
nature  of  the  case  has  been  from  the  first  evident ; 
but  in  other  examples  the  diagnosis  has  been  actually 
complicated  by  the  presence  of  the  tumour.  A  good 
instance  of  the  latter  condition  is  afforded  by  Dr.  Hall 
Davis's  case  of  tubal  pregnancy.  The  patient  was  aged 
thirty-two,  and  was  seized  with  symptoms  of  acute  in- 
testinal obstruction  that  ended  in  death  on  the  ninth 
day.  A  fixed  and  tender  tumour  could  be  felt  in  the 
right  iliac  fossa,  vaginal  examination  revealed  nothing 
abnormal,  and  "  all  certain  signs  of  pregnancy  were 
absent."  The  tumour  depended  upon  a  tubal  preg- 
nancy and  had  occluded  the  csecum  by  pressure. 

In  some  of  the  cases  there  had  been  no  evidence 
of  intestinal  trouble  previous  to  the  final  attack. 

In  certain  of  the  chronic  cases  the  symj^toms 
were  precisely  like  those  of  stricture  of  the  intestine, 
the  progress  of  the  case  being  marked  by  paroxysmal 
attacks  from  time  to  time.  In  other  instances  there 
was  simply  an  increasing  constipation  that  occasioned 
no  great  amount  of  disturbance  until  it  became  ab- 
solute, and,  after  resisting  all  attempts  at  relief,  ended 
in  death. 


319 


CHAPTER    XVI. 

OBSTRUCTION    OF    THE    INTESTINE    BY     FOREIGN    BODIES. 

By  a  "  foreign  body  "  as  applied  to  the  intestinal 
tract  is  meant  any  substance  that  can  resist  the 
digestive  action  of  the  fluids  of  the  stomach  and 
bowels. 

These  substances  may  be  swallowed  by  accident, 
or  during  fright,  or  they  may  be  taken  intentionally. 
It  would  appear  that  in  several  instances  swindlers 
endeavouring  to  pass  false  coin  have  swallowed  the 
spurious  pieces  to  escape  detection.  Some  of  these 
foreign  substances  have  been  swallowed  with  suicidal 
intent.  A  great  many  of  the  reported  cases  have 
occurred  in  the  persons  of  lunatics  and  in  the  subjects 
of  hysteria.  In  not  a  few  instances  the  substance 
has  slipped  down  the  throat  during  sleep  or  un- 
consciousness from  antesthesia,  and  this  especially 
applies  to  false  teeth. 

These  foreign  bodies  may  be  conveniently  divided 
into  three  classes  :  1.  Rounded  or  regularly-shaped 
substances  that  may  be  considered  capable  of  passing 
readily  through  the  intestine.  Among  such  are 
pebbles,  stones,  fruit  stones,  coins,  bullets  and  the 
like.  2.  Sharp-pointed  bodies  and  substances  of 
irregular  shape  that  may  readily  catch  in  the  mucous 
membrane  or  are  of  an  outline  that  would  favour  their 
becoming  fixed  in  the  alimentary  passages.  Such  are 
pins,  needles,  hooks,  plates  carrying  false  teeth,  pieces 
of  bone,  pieces  of  metal  or  of  porcelain,  nails,  screws, 
and  other  such  substances,  many  of  which  have  been 
frequently    found    in   the   intestine    or   have    passed 


;5  2  0  IntES  TINA  L    ObS  TR  UC  TION.  [Chap.  X Vl. 

through  it.  3.  Indigestible  materials  of  small  size 
which  are  apt  to  accumulate  until  they  form  huge 
masses.  Indeed,  the  largest  foreign  substances  found 
in  the  alimentary  canal  have  been  of  this  character. 
They  are  composed  of  husks  of  the  oat,  vegetable 
fibres,  grape  skins,  or  of  hairs,  or  of  wool  or  yarn. 
The  latter  materials  have  either  been  swallowed  as  a 
matter  of  habit  by  dressmakers  and  others,  or  have 
been  intentionally  taken  by  lunatics  and  hysterical 
individuals. 

There  is  no  doubt  but  that  the  majority  of  the 
foreign  substances  that  are  swallowed  are  in  time 
passed  by  the  anus.  Most  of  those  placed  in  the  first 
of  the  above  classes  would  be  so  evacuated  in  the 
course  of  a  few  days  or  even  after  forty-eight  hours. 
Others  would  be  retained  for  a  week  or  fortnight  or 
longer  without  causing  inconvenience.  Many  foreign 
substances  that  may  be  placed  in  the  second  class 
have  also  been  passed  with  comparatively  little  in- 
convenience. Some  of  such  bodies  have  lingered  in 
the  alimentary  tube  for  weeks,  for  months,  and  even 
for  years.  How  many  of  these  substances  pass  the 
pylorus  and  the  ileo-csecal  valve  must  remain  an 
anatomical  mystery.  Thus,  in  the  College  of  Surgeons 
Museum  is  a  specimen  (No.  1,184)  showing  a  dessert- 
spoon seven  inches  long  and  with  a  bowl  one  and 
a  half  inches  wide  lying  fixed  in  the  ciecum.  The 
spoon  is  quite  unaltered  in  shape  and  had  been 
swallowed  by  a  lunatic.  Mr.  Pollock  C[Uotes  a  case 
where  a  plate  carrying  six  false  teeth  was  swallowed 
and  passed  at  the  end  of  three  days.  In  another  like 
instance  where  the  plate  held  together  four  teeth  the 
mass  was  evacuated  per  anum  at  the  end  of  six 
months.*  In  Dr.  Marcet's  celebrated  case  a  sailor 
swallowed    clasp-knives    from    time   to    time    until 

*  Holmes'  System  of  Surgery,  vol.  i.,  page  DIO,  .3rrl  cd. 
Lond..  1888. 


Chap.  y^ww.  Obstruction  by  Foreign  Bodies.      321 

he  had,  in  a  period  of  ten  years,  consumed  thirty- 
seven  in  all.  Many  of  these  were  passed  per  anum 
entire,  others  in  fragments.^  A  door-key  was  passed 
in  another  case  four  days  after  it  was  swallowed,  f 
In  another  instance  a  piece  of  a  horse-slioe  was 
passed  at  the  end  of  two  months.  %  In  the  intestine 
of  one  lunatic  were  found  three  cotton  reels,  two 
bandages  partly  unrolled,  some  skeins  of  thread,  and 
a  pair  of  braces.  Among  other  strange  substances 
that  have  passed  the  whole  length  of  the  alimentary 
canal  may  be  mentioned  the  following :  a  pencil- 
case,  a  dagger-blade,  a  small  flute,  a  long  breast-pin, 
and  a  brace  buckle. 

When  the  foreign  substance  is  not  passed  per 
vias  naturales  it  is  apt  to  remain  lodged  in  certain 
special  parts  of  the  tube,  viz.  in  the  stomach,  the 
duodenum,  the  lower  end  of  the  ileum,  the  caecum  or 
the  rectum.  Of  all  these  situations  the  csectim  is 
the  one  in  which  lodgment  is  most  likely  to  take 
place. 

As  a  foreign  body  passes  along  the  canal  it  may 
cause  obstruction  at  any  point,  and  that  obstruction 
may  prove  fatal.  The  progress  of  the  larger  and 
more  irregular  substance  is  marked  by  pain,  by 
attacks  of  temporary  obstruction  associated  with 
colic,  vomiting,  and  constipation.  In  other  instances 
an  impacted  foreign  body  has  given  rise  to  long 
continued  symptoms  of  partial  obstruction,  symptoms 
that  may  become  very  chronic  yet  never  severe. 

There  is  plenty  of  evidence  to  show  that  these 
bodies  may  remain  for  weeks,  months,  or  years  in  the 
stomach  or  in  some  part  of  the  intestine  without 
causing  active  mischief,  but  that,  when  so  lodged,  they 
may   almost   at   any  time  induce  changes  leading  to 

*Med..-Chir,  Trans.,  vol.  xii.,  page  52. 
■]^  Lancet,  vol.  i,,  1870,  page  757. 
X  Ibid.,  vol.  ii.,  1874,  page  574. 

V— 12 


32  2  Intestinal  Obstruction.       [Chnp.  xvi. 

a  fatal  result.  Moreover  even  when  they  have  been 
long  retained  they  may  be  safely  discharged  by  the 
natural  passages.  Thus  in  one  of  Mr.  Pollock's  cases 
a  plate  carrying  false  teeth  had  been  swallowed,  and 
after  remaming  in  the  stomach  for  ninety-seven 
days  was  finally  ejected  by  vomiting.  The  impacted 
foreign  substance,  however,  is  very  apt  to  induce  some 
ulceration  of  the  mucous  membrane.  This  may  lead 
to  perforation  and  to  fatal  peritonitis  ;  or  some  local 
chronic  peritonitis  may  be  excited  in  the  part  lodging 
the  substance  and  the  gut  may  become  thereby  nar- 
rowed. Such  narrowing  may  increase  after  the 
evacuation  of  the  body,  and  may  lead  to  obstruction. 
According  to  Leichtenstern,  "  foreign  bodies  give  rise, 
more  frequently  than  gall  or  intestinal  stones,  to  a 
constriction  by  cicatricial  bands  or  chronic  peritonitis, 
at  the  spot  where  they  have  remained  for  a  long  time." 

In  another  class  of  cases  the  ulceration  of  the 
mucous  membrane  leads  to  the  formation  of  a  fistula 
through  which  the  foreign  body  may  be  discharged. 
This  fistula  may  communicate  with  the  exterior.  Thus 
in  the  College  of  Surgeons  Museum  is  a  specimen  (No. 
1,187)  from  a  boy,  aged  eleven,  where  many  cherry 
and  plum  stones,  that  had  been  swallowed,  were  dis- 
charged through  an  exterjial  abscess.  The  fistula 
may  form  between  the  stomach  and  the  transverse 
colon,  or  between  the  ileum  and  the  colon,  or  even 
between  the  coil  lodging  the  foreign  body  and  the 
rectum  or  tlie  vagina.  By  such  fistulous  channels  has 
the  substance  been,  after  a  long  interval,  evacuated. 

With  regard  to  small  sharp-pointed  bodies,  like 
needles,  they  may  readily  penetrate  the  intestine  and 
work  their  way  to  the  surface,  where  they  may  be 
recognised  and  removed.  Thus  I  extracted  from 
under  the  skin  of  the  groin  a  needle  that  had  been 
swallowed  by  a  child  some  months  previously. 

The  foreign  bodies  of  the  third  class  that  cause 


Chap.  XVII.]  Obstruction  by  Gall  Stones,         323 

obstruction  by  accumulation  may  form  immense 
masses.  When  in  the  intestine  they  may  lead  to 
chronic  and  fatal  obstruction,  or  may  induce  chronic  or 
acute  peritonitis.  Thus  Marshall  mentions  an  occlu- 
sion of  the  duodenum  by  a  pound  of  pins  that  had 
been  swallowed."^  In  an  instance  quoted  by  Duchaus- 
soy  in  his  memoir  the  obstructing  mass  was  composed 
of  seven  hundred  cherry-stones.  In  a  case  recorded 
by  Dr.  Quain  the  mass  consisted  of  four  pounds  of 
cocoanut  fibre,  f 

It  is  unnecessary  to  deal  here  with  those  numerous 
cases  in  which  foreign  substances  of  various  kinds 
have  been  accidentally  or  intentionally  introduced 
into  the  rectum  and  have  caused  more  or  less  obstruc- 
tion. The  matter  belongs  rather  to  another  branch 
of  surgery. 


CHAPTER  XYII. 

OBSTRUCTION    OF    THE    INTESTINE.  BY    GALL    STONES. 

The  lumen  of  the  intestine  may  be  obstructed  at  cer- 
tain points  by  a  gall  stone  that  has  entered  it  from  the 
gall  bladder  and  is  passing  along  its  way  to  be  dis- 
charged at  the  anus.  In  the  fii'st  place,  however,  it 
must  be  acknowledged  that  in  the  great  majority  of 
cases  the  gall  stone  passes  without  any  difficulty  along 
the  intestine,  and  without,  indeed,  exciting  symptoms 
of  any  kind.  The  instances  where  obstruction,  whether 
temporary  or  permanent,  is  produced  must  be  re- 
garded as  quite  rare  and  exceptional,  although  the 
gross  number  of  such  instances  is  not  small.  It  may 
be  surmised  that  a  stone   that  will   pass  along  the 

*Med.-Chir.  Trans.,  vol.  xxxv.,  page  65. 
fPath.  Soc.  Trans.,  vol.  v.,  page  145. 


324  Intestinal  Obstruction.      [Chap.  xvii. 

narrow  and  somewhat  rigid  bile-duct  cannot  expect 
to  meet  with  any  obstruction  in  the  intestine.  Even 
the  lumen  of  the  ileo-csecal  valve  is  many  times 
greater  than  is  that  of  the  common  duct.  But  the 
gall  stones  that  cause  occlusion  do  not  usually  enter 
the  intestine  by  the  biliary  passage.  They  enter  by 
means  of  a  temporary  fistulous  communication  between 
the  gall  bladder  and  the  duodenum.  In  very  rare  ex- 
amples the  communication  has  been  between  the  gall 
bladder  and  the  colon  at  the  hepatic  flexure.  Indeed, 
it  appears  to  me,  after  examining  a  large  number  of 
cases,  that  at  present  decided  evidence  is  lacking  that 
would  show  that  a  biliary  calculus  that  has  passed 
along  the  bile  duct  is  capable  of  causing  obstruction 
symptoms  when  it  reaches  the  intestine.  In  many  of 
the  reported  cases  the  condition  of  the  gall  bladder  is 
not  stated.  In  a  case  placed  on  record  by  Dr.  John 
Abercrombie  it  would  appear  that  the  calculus  had 
reached  the  bladder  through  the  duct.  The  patient 
was  a  man,  aged  forty-five,  who  died  of  acute  ob- 
struction lasting  five  days.  He  had  had  previous 
obstructive  attacks.  In  the  ileum  was  impacted  a 
gall  stone  measuring  four  inches  in  its  largest  circum- 
ference and  three  and  a  half  in  its  least.  The  com- 
mon duct  easily  admitted  a  finger.  Then  in  the 
account  comes  the  following  statement,  which  serves  to 
throw  some  doubt  upon  the  mode  of  entrance  of  the 
stone  :  "  The  gall  bladder  was  in  a  state  of  inflam- 
mation and  was  softened  and  partially  disorganised."* 
As  to  the  size  of  the  calculus  that  may  cause  oc- 
clusion it  must  be  noted  that  stones  of  considerable 
dimensions  have  been  spontaneously  evacuated.  Thus 
calculi  have  passed  the  anus  measuring  2^  inches  by 
\\  inches,  and  presenting  a  circumference  of  2>\ 
inches.      Cases  of  the  evacuation  of  stones  so  large  as 

*  Path,  and  Pract.  Researches  ou  Diseases  of  the  Stomach, 
etc.,  page  127,  3rcl  ed.    London,  1837. 


Chap.  XVII.  1  Obstruction  by  Gall  Stones.         325 

these  are  by  no  means  uncommon.  The  calculi  that 
have  been  found  impacted  in  the  bowels  have  in 
many  instances  attained  considerable  dimensions.  As 
examples  I  might  mention  the  following  :  a  stone 
measuring  4|  inches  by  2-|  inches  lodged  in  the  upper 
part  of  the  jejunum;'*^  one  with  a  circumference  of 
3|-  inches  impacted  in  the  lower  jejunum ;  f  one  2 
inches  in  length  and  with  a  circumference  of  4  inches, 
also  in  the  jejunum  ;  %  and  another  1  inch  in  length 
and  with  a  like  circumference  impacted  in  the  ileum.  § 
An  interesting  case  has  been  recorded  of  a  woman, 
aged  sixty-three,  who  after  presenting  for  five  days  the 
symptoms  of  complete  intestinal  obstruction  passed  a 
gall  stone  of  more  than  1  inch  in  diameter.  She  had 
an  irreducible  enterocele  through  which  the  calculus 
must  have  passed. 

Some  of  the  larger  gall  stones  appear  as  casts  of 
the  gall  bladder  which  they  probably  entirely  occupied 
before  they  were  discharged.  It  must  be  remem- 
bered that  a  gall  stone  when  once  lodged  in  the 
intestine  may  become  enlarged  by  subsequent  deposit 
upon  it  of  earthy  matters.  Leichtenstern  describes 
such  a  stone  that  had  a  circumference  of  about  5 
inches,  and  a  diameter  of  about  \\  inches. 

The  point  in  the  intestinal  tube  at  which  the 
stone  lodges  is  most  frequently  in  the  lowest  part  of 
the  ileum  or  in  the  duodenum  and  commencement  of 
the  jejunum.  An  examination  of  thirty-two  cases  by 
Lei(;htenstern  gives  the  following  result : 

In  tho  (luodcnum  and  jejunum  .  . 
In  tho  middlo  ileum  .... 
In  the  lower  part  of  ileum  . 

32 

*  Mr.  E.  Pye  Smith  ;  Path.  Soc.  Trans.,  vol.  v.,  page  163. 
t  Dr.  Baly  ;  ibi<l.,  vol.  x.,  page  184. 

X  Revue  Med.  dc  la  Suisse  Roviande,  No.  2,  1882,  page  82. 
i^  Dr.  Muichisou  ;  Path.  Soc.  Trans.,  vol.  xx.,  page  219. 


10 

cases 

5 

)> 

17 

» 

326  Intestinal  Obstruction.      [Chap.  xvii. 

In  sixteen  recorded  cases  collected  by  myself  a 
very  similar  result  is  to  be  noticed. 

It  is  obvious  that  if  the  calculus  has  passed  the 
small  intestine  and  the  valve  it  can  hardly  become 
impacted  in  the  colon,  although  there  may  be  some 
difficulty  in  the  way  of  its  evacuation  from  the  anus. 
In  all  the  fatal  cases  of  obstruction  by  a  calculus  the 
impaction  has  been  always  in  the  lesser  bowel. 

In  cases  of  occlusion  by  gall  stones  sex  and  age 
have  much  influence.  The  condition  is  much  more 
frequent  in  females  than  in  males  and  usually  con- 
cerns those  who  have  passed  middle  life.  The  pro- 
portion of  females  to  males  is  nearly  that  of  four  to 
one.  The  average  age  of  the  patients,  as  estimated 
from  sixteen  cases,  was  fifty-seven  years.  They  w^ere, 
Avith  one  exception,  all  over  the  age  of  forty.  The 
youngest  patient,  the  exception  just  alluded  to,  was 
a  woman  aged  twenty-seven.*  The  oldest  patient  was 
a  woman  aged  seventy-eight. 

With  regard  to  the  clinical  aspects  of  these  cases 
it  will  be  evident  that  there  need  be  no  history  of 
hepatic  colic  in  a  given  instance  if  it  be  true  that  the 
stone  usually  reaches  the  duodenum  by  ulceration 
from  the  gall  bladder. 

In  many  of  the  cases  there  has  been  no  histoiy  of 
hepatic  colic ;  in  others  there  have  been  such  attacks, 
which  depended,  however,  most  probably  upon  the 
passage  of  smaller  calculi  previous  to  the  entrance 
into  the  bowel  of  the  large  stone  that  caused  ob- 
struction. There  are  instances  where  the  patient 
was  practically  free  from  any  abdominal  symptoms  up 
to  the  time  of  the  final  obstructive  attack.  Dr.  W. 
H.  Draper  has  recorded  an  excellent  example  of  this 
circumstance.!  On  the  other  hand  are  examples 
showing  evidence  of  local  peritonitis  in  the  vicinity  of 

*  Dr.  Peacock  ;  Path.  Soc.  Trans.,  vol.  i.,  page  255. 
f  New  York  Med.  Journ.,  vol.  xxxvi.,  1882,  page  17. 


Chap.  XVII.]  Obstruction  BY  Gall  Stoxes.         327 

the  gall  bladder  and  associated  with  symptoms  that 
may  be  very  properly  ascribed  to  the  passage  of  the 
stone  direct  from  the  bladder  into  the  duodenum.  As 
to  the  length  of  time  that  may  elapse  between  the 
passage  of  the  calculus  into  the  gut  and  the  appear- 
ance of  obstructive  symptoms  there  is  little  to  be  said 
definitely,  owing  to  the  vagueness  of  the  symptoms 
that  mark  such  passage.  In  several  cases  the  estab- 
lishment of  a  fistulous  communication  between  the 
gall  bladder  and  the  duodenum  appears  to  have  been 
effected  without  producing  any  noticeable  symptoms. 
In  many  instances  symptoms  of  obstruction  have 
appeared  veiy  soon  after  the  supposed  entrance  of  the 
stone  into  the  bowel,  and  in  other  cases  a  long  in- 
terval has  elapsed.  Thus  in  one  example  there  was 
evidence  of  local  peritonitis  in  the  right  hypochon- 
drium  three  months  before  the  final  attack  of  obstruc- 
tion, but  in  the  interval  the  patient  had  not  been 
wholly  free  from  intestinal  symptoms."^  I  cannot 
think  with  Leichtenstern  that  so  long  a  period  as 
three  years,  as  he  maintains,  can  elapse  between  the 
introduction  of  the  stone  into  the  intestine  and  the 
development  of  obstructive  symptoms.  Attacks 
occurring  at  so  long  a  period  before  the  final  attack  of 
obstruction  were  probably  instances  of  hepatic  colic 
due  to  the  passage  of  stones  along  the  bile  duct,  stones 
that  had  long  since  been  evacuated  from  the  bowel. 
In  one  instance  the  local  disturbance  incident  to  the 
passage  of  the  stone  from  the  gall  bladder  into  the  gut 
appears  to  have  been  associated  with  very  marked 
symptoms.  The  patient  was  a  woman,  aged  fifty-four, 
w^ho,  six  weeks  before  an  attack  of  obstruction  that 
ended  in  death,  had  had  an  abscess  opened  in  the 
right  hypochondrium  that  was  supposed  at  the  time 
to  have  been  connected  with  the  liver,  j 

*  Path.  Soc.  Trans.,  vol.  v.,  page  163. 

t  Revue  Med.  de  la  Suisse  Romande,  No.  2, 18S2  ;  Dr.  Carrard. 


328  InTES TINA L    ObS TR  UC TION.        [Chap.  XVI I. 

In  some  cases,  and  perhaps  in  a  large  number  of 
cases,  a  gall  stone  of  considerable  magnitude  may 
pass  along  tlie  bowel  without  exciting  any  marked 
disturbance,  and  may  indeed  only  cause  trouble  when 
it  comes  to  be  evacuated  at  the  anus.  In  other  in- 
stances the  passage  of  the  calculus  is  marked  by 
attacks  of  colic  from  time  to  time,  by  irregularity  in 
the  motions,  by  some  meteorism,  and  by  vomiting. 
The  symptoms  may  be  very  severe  while  they  last,  and 
indicate,  no  doubt,  a  complete  but  temporary  obstruc- 
tion. The  symptoms  after  being  violent  are  not  in- 
f I'equently  suddenly  relieved,  and  the  patient  passes  in 
a  few  moments  from  a  state  of  intense  suffering  to  a 
condition  of  almost  perfect  ease.  Such  a  transition 
is  probably  coincident  with  the  passage  of  the  con- 
cretion through  the  ileo-caecal  valve  into  the  colon, 
where  it  ceases  to  give  trouble.  The  length  of  time 
that  may  intervene  between  an  attack  of  obstruction 
and  the  actual  passage  of  the  stone  may  be  consider- 
able.    It  may  amount  to  one  or  two  weeks. 

In  a  great  number  of  the  cases  the  clinical  history 
is  as  follows  :  The  patient  dies  of  an  attack  of  intes- 
tinal obstruction  that,  so  far  as  its  duration  is  con- 
cerned, may  be  called  acute.  In  these  attacks  there 
will  be  pain  of  a  more  or  less  persisting  nature  and 
of  a  colicky  character,  vomiting  that  may  become 
stercoraceous,  constipation  that  soon  develops  into 
absolute  obstruction  and  more  or  less  meteorism  of 
the  abdomen.  These  attacks  do  not,  as  a  rule, 
develop  suddenly.  They  are  not  associated  with  the 
severe  pain  that  marks  some  forms  of  acute  obstruc- 
tion, such  as  strangulation  by  a  band,  and  as  a  con- 
sequence are  not  attended  by  much  collapse,  if  by  any 
at  all.  The  vomiting  is  often  very  copious,  and  in 
the  majority  of  the  cases,  where  the  lower  ileum  is 
concei-ned,  becomes  feculent  ])ofore  death.  There  is 
no  marked  abdominal  tenderness  unless  peritonitis  be 


Chap.  XVII.]  Obstruction  BY  Gall  Stones,         329 

developing,  and  the  amount  of  meteorism  is  usually 
quite  slight.  I  can  find  no  case  where  any  definite 
tumour  was  detected,  in  no  such  case  was  there  any 
tenesmus,  and  in  no  instance  any  evacuation  of  blood. 

In  one  instance,  where  death  followed  in  five  days, 
the  patient,  a  woman  of  sixty-nine,  was  seized  with 
cramps  and  died  comatose. 

The  average  duration  of  these  somewhat  acute  final 
attacks  is  seven  days.  The  shortest  period  being  four 
days,  the  longest  fifteen  days. 

These  attacks  have  often  been  preceded  by  similar 
evidences  of  obstruction,  which  may  or  may  not  have 
been  brought  about  by  the  same  stone.  Thus  one 
patient  had  two  attacks  only,  the  previous  one  occur- 
ring three  months  before  death,  another  had  three 
attacks  that  appeared  eighteen  months,  twelve  months, 
and  six  days  respectively  before  death.  In  another 
instance  the  patient  is  described  as  having  many 
attacks  of  a  nature  akin  to  that  that  proved  fatal  in 
the  end. 

In  the  intervals  between  such  attacks  the  bowels 
have  usually  been  irregular  and  the  patient  liable  to 
digestive  disturbances  and  to  sickness ;  or  in  the 
absence  of  such  attacks  there  may  have  been  some  in- 
testinal irregularities  simply  or  certain  symptoms  that 
would  have  been  associated  with  the  passage  of  the 
stone  into  the  intestine. 

In  another  set  of  cases  the  obstruction  leading  to 
death  has  been  more  chronic.  There  has  been,  perhaps, 
absolute  constipation  for  twenty  days  before  the 
individual's  decease,  and  the  progress  of  the  case  has 
been  indolent  and  gradual.  Such  cases  also  may  or 
may  not  have  been  associated  with  previous  attacks  of 
intestinal  disturbance.  In  these  more  chronic  cases 
all  the  symptoms  are  less  marked.  The  pain  may  be 
intermittent,  the  vomiting  is  less  pronounced  and 
is  rarely  feculent,  there  may  be  some  meteorism,  and 


330  Intestinal   Obstruction.      [Chap.  xvii. 

the  coils  of  intestine  may  be  visible  through  the 
parietes. 

In  a  third  series  of  cases  the  stone  would  appear  to 
cause  but  partial  obstruction,  and  symptoms  are  pro- 
duced that  are  identical  with  those  of  stricture  of  the 
small  intestine.  That  is  to  say,  there  are  attacks  from 
time  to  time  of  paroxysmal  pain,  some  vomiting  that 
rarely  becomes  feculent  until  quite  the  end  of  the  case, 
and  constipation  that  may  not  become  absolute,  and 
that  may  be  relieved  by  aperients  and  enemata.  The 
coils  of  intestine  also  will  be  visible  if  the  patient  be 
thin.  The  symptoms  will  often  be  aggravated  by  food 
and,  indeed,  the  whole  aspect  of  the  case  closely 
resembles  that  of  a  case  of  stricture.  Such  cases  are 
apt  to  end  by  an  acute  attack,  the  partial  obstruction 
becoming  com]jlete. 

Apropos  of  partial  obstruction,  it  should  be  noted 
that  an  impacted  calculus  may  in  time  push  out  a 
divei-ticulum  from  the  intestinal  wall  and  become 
encysted  without  offering  a  great  obstacle  to  the 
passage  of  intestinal  matters.  This  is  said  to  occur 
most  frequently  in  the  duodenum,  although  it  has  been 
also  met  with  in  the  ileum. 

It  will  be  obvious  that  the  symptoms  will  depend 
somewhat  upon  the  position  of  the  calculus  in  the  in- 
testine. The  nearer  the  obstruction  to  the  stomach 
the  more  marked  is  the  vomiting,  and  the  less  marked, 
or  the  longer  delayed,  are  the  evidences  of  interference 
with  the  action  of  the  bowels.  In  some  cases  of  im- 
paction in  the  duodenum  the  vomiting  has  been  very 
severe.  The  symptoms  have  become  almost  imme- 
diately exaggerated  by  the  taking  of  food,  while  con- 
stipation has  not  become  pronounced  until  the  other 
symptoms  have  existed  for  some  time.  In  the  case  of 
Dr.  Pye  Smith's,  already  alluded  to,  the  gall  stone  was 
in  the  upper  part  of  the  jejunum.  The  vomiting  was 
profuse,  no   less  than  one  and   a  quarter  gallons  of 


Chap.  XVII.]  Obstruction  BY  Gall  Stones.         331 

bilious  fluid  having  been  ejected  in  forty-eiglit  hours. 
The  patient  died  on  the  sixth  day  after  the  commence- 
ment of  the  symptoms. 

It  may  here  be  convenient  to  note  two  or  three 
anomalous  cases  which  possess  some  interest. 

It  Avould  appear  that  under  some  cii'cum stances 
the  obstruction  of  the  intestine  is  much  assisted  by 
an  abrupt  l)ending  of  the  bowel  at  the  point  of 
impaction  of  the  stone.  Such  bending  may  at  least 
render  a  partial  occlusion  a  complete  one. 

Thus,  in  the  case  from  which  Fig.  54  was  taken, 
the  gut  was  not  only  blocked  by  a  large  gall-stone,  but 
the  intestine  w^as  acutely  bent  upon  itself  and  fixed 
in  that  position  by  adhesion  of  its  peritoneal 
surfaces.*  In  another  instance,  where  such  a  bend 
had  developed,  the  calculus  w^as  at  the  extreme  angle 
of  the  bend,  and  there  is  little  doubt  but  that  the 
altered  contour  of  the  bowel  was  the  cause  of  the 
complete  obstruction  that  existed. f  In  one  remark- 
able case  the  pressure  of  the  stone  had  produced 
gangrene  of  the  gut  in  two  places.  The  calculus  was 
found  in  the  ileum  and  was  covered  by  a  gangrenous 
piece  of  intestine.  Higher  up  in  the  ileum  w^as 
another  patch  of  gangrene  one  inch  square.  At  this 
point  fatal  perforation  had  occurred.  The  calculus  had 
a  circumference  of  three  inches,  and  the  patient,  a 
woman  of  sixty-eight,  had  had  more  or  less  severe 
attacks  of  intestinal  obstruction  for  the  six  weeks 
that  preceded  her  death.  1 

In  a  case  placed  on  record  by  M.  Cuflfer  the  patient 
died  of  an  obstruction  situated  in  the  hepatic  flexure 
of  the  colon.  The  caecum  was  enormously  distended 
and  had  become  perforated.     The  hepatic  flexure  was 

*  Middlesex  Hosp.  Museum,  No.  viii.  57.  See  also  Path.  Soc. 
Trans.,  vol.  viii.,  page  231. 

•\Ne%o  York  Med.  Joum.,  1882,  page  17. 

+  Patli.  Soc.  Trans.,  vol.  ix.,  page  203;  Dr.  Scott  Allison. 


332 


tChap.  XVII. 


FJfr.  54.  —Gall  Stone  impacted  iu  tho  Ileum.      A  section  Las  been  ni.ade 
of  the  Gall  Stone. 


Chap.  XVI 1. 1    OnSTRUCTION  BY    GaLL    StONES.  333 

adherent  to  the  under  surface  of  the  liver  by  many 
adhesions,  and  among  these  adhesions  was  a  gall  stone, 
the  size  of  a  boan.  The  bile  ducts  were  in  a  normal 
condition,  but  the  gall  bladder  had  been  destroyed. 
The  obstruction  was  due  to  a  narrowing  of  the  colon 
from  contraction  of  the  adhesions.  In  this  case  it  is 
most  probable  that  the  calculus  had  set  up  inflamma- 
tion in  the  gall  bladder,  that  that  structure  had  in 
consequence  become  adherent  to  the  colon,  and  that 
the  stone,  had  the  case  been  a  little  more  favourable, 
would  have  been  discharged  into  the  large  intestine 
and  so  have  escaped.  "'^ 

In  a  case  of  chronic  obstruction,  where  the 
diagnosis  rested  between  cancer  and  impacted  gall- 
stone, a  long  needle  was  repeatedly  thrust  into  the 
abdomen  at  various  points  in  the  hope  of  striking  the 
stone  should  one  exist.  The  stone  was  at  last  struck 
at  a  depth  from  the  surface  of  four  and  three  quarter 
inches.  No  inconvenience  followed  upon  the  use 
of  this  means  of  diagnosis.! 

In  another  instance  Dr.  George  Harley  \  struck 
an  impacted  calculus  in  the  bile  duct  by  means  of  a 
slender  trochar  which  had  been  introduced  through 
the  parietes  to  a  distance  of  six  inches.  The  patient 
died  twenty-seven  days  after  the  sounding.  This  and 
like  modes  of  examination  are  to  be  condemned  except 
in  very  special  cases.  When  a  distinct  tumour  can 
be  felt  or  when  the  site  of  the  obstruction  is  well 
localised,  it  may  be  excellent  practice  to  introduce  a 
needle  for  the  })urpose  of  searching  for  a  gall  stone  or 
other  foreign  substance  ;  but  when  these  indications 
are  lacking  I  imagine  that  a  surgeon  is  hardly  justified 
in  thrusting  a  needle  vaguely  through  the  abdominal 
parietes  for  the  purpose  of  obtaining  aid  in  diagnosis. 

*Bull.  de  la  Soc.  Anat.,  1875,  page  176. 

\Med.  Record  of  New  Yo^-k ;  Dr.  James  Whitaker,  1882, 

X  Paper  read  before  Med.-Chir.  Soc. ;  Lancet,  May  17,  1884, 


334  Intestinal  Obstruction.      [Chap.  xvii. 

Fifty  sucli  punctures  may  be  made  before  a  gall  stone 
impacted  in  some  parts  of  the  bowel  may  be  hit. 

Frog:no8is. — There  is  no  doubt  that  by  far 
the  gi'eater  majority  of  all  gall  stones  that  find  their 
way  into  the  intestine  pass  through  that  canal  without 
causing  any  definite  disturbance.  Biliary  calculi  are 
common  enough,  but  the  instances  in  which  they  cause 
intestinal  obstruction  may  be  regarded  as  compara- 
tively rare,  and  indeed  as  very  rare.  Leichtenstern  in 
a  total  of  1,152  cases  of  intestinal  occlusion  from 
various  causes  includes  only  forty-one  examples  of 
obstruction  by  gall  stones. 

It  is  still  open  to  some  question  whether  a  gall 
stone  that  has  passed  into  the  bowel  along  the 
common  duct  is  capable  of  producing  an  obstruction 
in  the  intestine,  provided  that  the  intestine  be  normal. 
The  calculus  may  be  arrested  above  a  stricture  or 
above  any  point  the  seat  of  a  stenosis ;  but  if  it  will 
pass  the  bile  duct  it  is  more  than  probable  that  it  will 
also  pass  the  ileo-csecal  valve,  especially  if  we  take 
note  of  the  large  and  strangely  shaped  foreign  bodies 
that  have  succeeded  in  passing  that  aperture. 

It  is  true  that  calculi  may  become  lodged  in  the 
csecum  and  may  cause  typhlitis,  etc.,  and  some  obstruc- 
tion has  been  offered  by  an  accumulation  of  small 
stones ;  *  but  putting  these  cases  aside,  the  matter 
remains  as  we  have  just  expressed  it. 

Then,  again,  quite  large  calculi,  calculi  that  may 
have  entered  the  duodenum  direct  from  the  gall 
bladder,  have  passed  through  the  intestine  without 
causing  symptoms  or  at  least  without  producing 
definite  obstruction  of  the  bowels. 

Finally  there  are  cases  where  stones  of  large  size 
have  become  impacted,  have  produced  severe  evidences 
of  occlusion  of  the  bowel,  and  have,  after  a  varying 
interval,  been  spontaneously  evacuated.    Indeed,  out  of 

* Se&  case  by  Mr.  V.  H.  Watson;  Edinh.  Med.  Journ.,  1868, 


Chap.  xviL]  Obstruction  by  Gall  Stones.         335 

twenty  cases  where  gall  stones  produced  definite  and 
severe  symptoms  of  obstruction  I  find  that  six 
patients  recovered  by  the  spontaneous  passage  of  the 
stone,  while  in  the  other  fourteen  instances  the 
obstruction  remained  unrelieved  and  led  to  death. 

Spontaneous  evacuation  of  the  stone  may  occur 
even  after  symptoms  of  great  severity.  Thus,  in  a 
case  recorded  by  Dr.  C.  Martin  the  patient  suflfered 
from  absolute  obstruction  lasting  six  days,  the  vomiting 
became  severe  and  was  at  last  stercoraceous.  But  on 
the  morning  of  the  seventh  day  a  motion  was  passed 
that  was  followed  by  the  evacuation  of  a  large  stone. 
The  patient  rapidly  recovered."^  The  concretion  had 
a  circumference  of  three  and  a  half  inches. 

In  another  case,  quoted  by  Dr.  Sands,  a  woman, 
aged  forty,  sufiered  from  obstruction  due  to  the 
impaction  of  a  gall  stone.  The  constipation  was  com- 
plete for  four  iveeks.  At  the  end  of  that  time  a 
motion  was  passed,  and  seven  days  later  a  biliary 
calculus  with  a  circumference  of  three  inches.  Ster- 
coraceous vomiting  commenced  on  the  third  day  and 
lasted  for  three  iveehs.  The  patient  had  been  treated 
by  aperients  and  by  enemata.  She  made  a  good 
recovery,  f 

Helief,  however,  may  be  aflTorded  by  other  means 
than  the  escape  of  the  stone  by  the  natm^al 
passages.  The  impacted  stone  may  excite  inflam- 
mation which,  passing  on  to  suppuration,  may  produce 
a  fistula  discharging  upon  the  surface,  and  through 
this  fistula  the  calculus  may  be  expelled.  Leichten- 
stern  well  observes  that  this  mode  of  cure  is  extremely 
rare,  but  quotes  no  example.  I  have  found  one 
recorded  case  that  bears  very  directly  upon  this 
matter.  It  concerned  a  child,  aged  ten,  who  had 
been  liable  for  some  time  to  attacks  of  indigestion 

*Bull.  de  la  Soc,  Anat.,  1875,  page  570.     Paris. 
■\New  York  Medical  Record,  vol,  xxxi.,  1882,  page  427. 


^S^  Intestinal  Obstruction.    [Chap.  xviii. 

and  bilious  vomiting.  Some  time  after  one  of  these 
attacks  a  fluctuating  swelling  appeared  in  the  right 
side  of  the  back.  This  was  incised  and  some  thin 
foetid  brown  pus  escaped.  The  discharge  was  followed 
in  four  days  by  the  evacuation  of  a  body  the  size  of  a 
nutmeg.  This  when  cleared  of  faeces  showed  a 
nucleus  the  size  of  a  large  pea  composed  wholly  of 
cholesterin.     The  child  did  well."^ 

In  another  instance  an  abscess  was  set  up  by  the 
process  involved  by  the  passing  of  a  calculus  from  the 
gall  bladder  to  the  duodenum.  This  abscess  was 
evacuated  externally  and  through  it  the  stone  might 
readily  have  passed.! 

Some  of  those  who  die  from  the  effects  of  obstruc- 
tion die  from  mere  exhaustion,  others  succumb  to 
acute  peritonitis  and  a  comparatively  small  number  to 
perforation  of  the  bowel  above  the  seat  of  the 
impaction. 

Mr.  Ward  has  ])laced  upon  record  a  case  of 
cicatricial  stricture  of  the  terminal  part  of  the  ileum, 
which  was,  without  much  doubt,  due  to  ulceration  set 
up  by  impacted  and  long-retained  gall-stones.  | 


CHAPTER    XVITI. 

OBSTRUCTION     BY     INTESTINAL     STONES. 

Intestinal  calculi  or  enteroliths  may  be  divided  into 
three  classes. 

1.   Concretions  formed  in  great  part  of  phospliate 
of  lime,  or  of  phosphate  of  magnesia,  or  of  the  triple 

*Dr,  Thorowgood  ;  Path,  Soc.  Trans.,  1877,  page  131. 
fDr.   Carrard ;  Revue  Med.  de  la  Suisse  Rom.,  No  2,  1882, 
page  82. 

X  Path.  Soc.  Trans.,  1852,  page  357, 


Chap,  xviii,]        Intestinal  Calculi.  337 

phosphate,   or   stones  formed    of    mixtures  of    these 
salts. 

Such  calculi  may  contain  also  some  carbonate  of 
lime  together  with  soda,  and  are  nearly  always  com- 
biiied  with  a  certain  amount  of  animal  matter  and 
occasionally  with  a  little  cholesterin.  In  appearance 
they  are  heavy  and  stone-like,  and  of  a  grey  or  pale 
brown  colour  when  cleared  of  faeces.  On  section 
they  show  a  concentric  arrangement  of  chalk-like  or 
dirty  white  layers.  With  such  layers  often  alternate 
others  of  a  brownish  colour.  In  outline  they  are 
rounded  or  oval,  and  often  appear  to  have  been 
polished  by  peristaltic  movements.  They  would 
appear  to  be  always  formed  around  a  nucleus  of  some 
indigestible  substance.  Among  such  may  be  men- 
tioned vegetable  fibres  and  husks,  hairs,  fruit-stones, 
biliary  calculi,  pieces  of  bone  and  little  foreign  bodies 
that  have  been  accidentally  swallowed. 

The  concretion  is  usually  single  and  of  quite 
small  size.  It  is  seldom  larger  than  a  chestnut, 
although  a  few  isolated  instances  of  large  stones  have 
been  recorded. 

In  Leichtenstern's  list  of  such  calculi  are  three 
whose  respective  circumferences  are  4|-,  1^,  and 
9  inches.  Mr.  P.  H.  Watson  records  one  1|  inches 
in  length  and  \\  inches  in  width.  In  cases  where 
several  stones  exist  they  will  usually  be  found  to 
be  facetted  by  mutual  contact  and  pressure.  In  a 
case  of  Monro's  twelve  calculi  were  evacuated,  and 
in  a  case  of  Niemeyer's  no  less  than  thirty-two  that 
collectively  weighed  two  and  a  half  pounds. 

2.  Enteroliths  of  low  specific  gravity  and  of 
irregular  form  that  are  porous  in  appearance  and 
have  the  consistence  of  compressed  sponge.  They 
are  composed  mainly  of  densely  felted  masses  of 
vegetable  fragments  mixed  with  particles  of  faecal 
matter  and  with  a  certain  amount  of  calcareous 
w— 12 


^^S  InTES TINA L    ObS TR UC TION.      [Chap.  XV 1 1 1 . 

material  similar  to  that  met  with  in  the  above  species 
of  stone.  Tliese  concretions  comprise  the  "oat 
stones  "  or  avenoliths  that  are  composed  of  the  indi- 
gestible fragments  of  oatmeal.  They  are  said  to  be 
not  infrequently  observed  in  Scotland  and  amongst 
people  where  much  coarse  oatmeal  is  eaten.  These 
stones  are  usually  small  and  single.  Leichtensteni 
states  that  there  are  seldom  more  than  two  together,* 
and  adds  that  they  vary  in  size  from  a  chestnut  to 
that  of  an  orange. 

Closely  allied  with  such  enteroliths  are  certain 
concretions  of  indigestible  matters  that  belong  per- 
haps more  properly  to  the  list  of  "foreign  bodies." 
{See  page  320.)  Thus  Dr.  Harley  reports  a  case 
in  a  man,  aged  fifty-six,  where  a  solid  mass  mea- 
suring nine  inches  in  length  and  six  and  a  half  in 
circumference  was  passed  after  five  weeks  of  suf- 
fering. It  was  composed  of  undigested  animal  mat- 
ters of  various  kinds  densely  felted  together.  The 
same  author  mentions  the  case  of  a  woman,  aged 
twenty-five,  who,  after  having  dysentery  for  two 
months,  passed  a  hard  mass  the  size  of  a  small  hen's 
%^'g.  The  mass  had  the  appearance  of  a  phos- 
phatic  calculus,  but  proved  upon  examination  to  be 
composed  solely  of  starch,  f  In  a  case  by  Dr. 
Down,  fatal  obstruction  was  caused  by  a  stone-like 
mass  the  size  of  a  hen's  ^^^g  that  had  become  impacted 
in  the  lower  ileum.  It  was  composed  of  densely 
packed  cocoa-nut  fibres,  and  had  probably  been  formed 
in  the  stomach  and  then  passed  into  the  bowel.  The 
patient  had  been  engaged  in  mat-making.  \ 

*  Dr.  Harley  reiiorts  a  case  where  twenty  oat-stones  had  been 
passed  at  different  times.  They  were  small,  were  the  colour  of 
brown  sandstone,  had  a  section  like  felt  and  floated  in  water. 
Path.  Soc.  Trans.,  vol.  xi.,  page  87. 

t  Ibid. 

+  Ibid.,  vol.  xviii.,  page  98.  For  other  cases  sec  Brit.  Med. 
Journ.,  March  29,  1884,  page  608. 


Chap.  XVI 1 1.] 


Intestinal  Calculi. 


339 


3.  Concretions  formed  of  insoluble  mineral  matters 
that  have  been  swallowed  as  medicines.  These  are 
most  frequently  coni[)Osed  of  magnesia.  In  a  case 
recorded  by  Mr.  Hutchinson  a  huge  mass  with  a  cir- 
cumference of  at  least  fifteen  inches  was  felt  in  the 
rectum.     It  had  a  surface  that  was  hard  and  rough 


Fig.  55.— Obstruction  of  tlie  small  Intestine  by  a  Concretion  of  Magnesia. 
The  wall  of  the  bowel  has  been  cut  away  in  two  places  to  show  the 
concretion. 


like  an  oyster  shell.  It  was  broken  up  and  removed 
at  several  sittings.  It  was  found  to  be  composed  of 
magnesia  and  iron  with  some  earthy  matters  and 
many  thousands  of  strawberry  seeds.  The  patient 
had  been  in  the  habit  of  taking  large  doses  of  car- 
bonate of  magnesia  and  of  iron.* 

*rath.  See.  Trans.,  vol.  vi.,  page  20.1. 


340  Intestinal  Obstruction.    [Chap.  xviii. 

Fig.  55  is  taken  from  a  specimen  in  St.  Thomas's 
Hospital  Museum,*  which  shows  the  small  intestine 
at  one  point  almost  entirely  blocked  by  a  dense  mass 
of  magnesia  which  fills  the  gut  for  several  inches. 
Bamberger  noticed  a  stone  containing  mainly  car- 
bonate of  lime  in  a  patient  who  had  taken  much  chalk 
for  years.  In  a  patient  of  Mr.  Erichsen's  a  small 
stone  was  passed  after  much  intestinal  irritation.  It 
was  of  a  dark  brown  colour  and  had  the  aspect  of 
a  uric  acid  calculus.  It  was  found  to  be  composed  of 
gum  benzoin.  The  patient  was  a  singer  and  had  been 
in  the  habit  of  taking  little  pills  of  gum  benzoin  to 
improve  his  voice. 

Enteroliths  are  most  commonly  found  in  the  colon 
and  with  especial  frequency  in  the  csecura.  In  the 
colon  they  often  occupy  the  sacculi  of  the  gut.  They 
are  often  met  with  also  in  the  rectal  ampulla  and 
more  rarely  in  the  ileum  and  in  true  and  false 
diverticula. 

Taken  collectively  they  may  be  said  to  be  met 
with  most  often  in  young  adults  and  in  individuals  of 
middle  age. 

Enteroliths  seldom  occasion  intestinal  obstruction. 
Leichtenstern  could  find  only  twenty  examples  among 
1,152  instances  of  obstruction  of  the  bowels.  Five  of 
these  patients  were  females  and  the  remaining  fifteen 
males. 

It  is  evident  that  these  stones,  especially  the  more 
calcareous,  are  of  very  slow  formation.  They  may 
moreover  be  dormant,  as  it  were,  for  years,  or  excite 
during  that  time  but  insignificant  symptoms.  In  Mr. 
Hutchinson's  case  of  magnesian  enterolith  the  patient 
was  an  elderly  woman.  She  had  been  in  the  habit  of 
taking  magnesia  and  iron  thirty  years  before  she 
came  under  observation,  and  she  had  discontinued  the 
use   of  those    drugs   for  no    less   than    twelve   years. 

*  No.  E  1. 


Chap.  xviTi.]        Intestinal  Calculi.  341 

For  the  eleven  years  that  preceded  the  evacuation  of 
tlie  concretion  she  had  simply  sufiered  from  constipa- 
tion. 

As  to  the  syiiiptoiiis  produced  by  enteroliths,  it 
may  be  at  first  said  that  they  vary  greatly  and  depend 
a  good  deal  upon  the  situation  of  the  mass  in  the 
intestine.  They  very  rarely  cause  sudden  occlusion  of 
the  bowel.  In  Dr.  Down's  case  of  cocoa-nut  fibre 
"  stone  "  the  patient,  an  idiot  boy  aged  sixteen,  died 
of  acute  obstruction  that  lasted  for  fifteen  days.  In 
this  instance  the  mass  had  probably  been  formed  in 
the  stomach,  and  passing  into  the  bowel  had  occluded 
it.  In  other  cases  also  of  sudden  occlusion  the  calculi 
have  been  formed  in  diverticula  of  the  small  intestine 
and  have  then  made  their  way  into  the  bowel  and 
suddenly  occluded  it. 

Apart  from  rare  cases  such  as  these  the  symptoms 
of  intestinal  stone  are  distinctly  chronic.  In  some 
instances  there  is  a  history  of  long  continued  digestive 
disturbances,  with  occasional  attacks  of  pain  and 
sickness,  and  with  generally  some  amount  of  constipa- 
tion. The  patients  indeed  present  the  symptoms  of 
a  persisting,  incomplete,  and  inert  obstruction  in  the 
intestine.  They  are  apt  to  become  emaciated  and 
hypochondriacal.  Symptoms  such  as  these  may  con- 
tinue for  years.  In  Mr.  P.  H.  Watson's  case,  to 
which  allusion  has  been  already  made,  the  patient, 
a  man  over  fifty,  had  had  evidences  of  abdominal 
trouble  for  no  less  than  twenty  years ;  and  in  other 
instances  the  symptoms  have  lasted  for  four,  for  six, 
and  for  seven  years  before  the  evacuation  of  the 
sto]ie.  The  mass  also  is  not  infrequently  to  be  felt. 
In  Mr.  Watson's  remarkable  case  a  large  mass  was 
felt  in  the  right  hypochondrium  some  years  before 
the  enterolith  was  evacuated.  This  mass  gradually 
moved  towards  the  left  hypochondrium  and  then 
disappeared.       Its    disappearance    was    immediately 


342  Intestinal  Obstruction.    [Chap.  xviii. 

followed  by  evidences  of  a  foreign  substance  in  the 
rectum.  In  Dr.  Dowii's  case  also  the  mass  of  fibre 
could  be  felt  through  the  parietes.  It  is  needless 
to  say  that  many  concretions  have  been  detected  by 
rectal  examination  when  they  occupy  the  terminal 
part  of  the  bowel. 

In  other  cases,  the  calculus  when  lodged  in  the 
caecum  may  cause  typhlitis  or  perityphlitis  and  may 
finally  lead  to  perforation  and  death. 

When  lodged  in  the  ampulla  the  patient  presents 
all  the  symptoms  of  a  foreign  substance  in  the  rectum. 

The  pi'Og^iiosis  is  good  on  the  whole,  since  in 
the  great  majority  of  the  cases  the  concretion  is 
either  spontaneously  evacuated  or  is  removed  by 
forceps  from  the  rectum.  As  already  stated,  cases  of 
fatal  obstruction  are  extremely  rare.  It  is  not  im- 
probable that  an  enterolith  that  forms  a  tumour  to  be 
felt  through  the  parietes  and  that  is  associated  wdth 
emaciation  and  chronic  obstruction  may  be  mistaken 
for  a  case  of  cancer  of  the  bowel. 

It  is  probable  that  some  of  the  so-called  entero- 
liths that  have  been  passed  have  been  merely  unusually 
hard  scybala. 

It  will  here  be  con^'enient  to  mention  the  subject 
of  certain  skin-like  cylinders  that  are  sometimes 
evacuated  from  the  bowel.  Thus,  in  a  case  recorded 
by  Mr.  Hutchinson,*  the  patient,  a  woman  aged 
forty-nine,  passed  for  several  months  "  skins,"  some 
of  which  were  many  inches  in  length,  while  others 
attained  a  length  of  several  feet.  She  was  at  the 
same  time  troubled  with  diarrhoea,  bloody  evacuations, 
some  vomiting,  and  epigastric  pain. 

These   cylinders  are  composed  of  mucus  and  are 

the  products  of  a  certain  form   of  chronic  intestinal 

catarrh.      Speaking  of  the  presence  of  mucus  in  the 

stools    in    intestinal    catarrh,   Leube    says,    "  In   rare 

*  Path.  Soc.  Trans.,  vol.  ix.,  page  188. 


Chap.  XVIII.]    Intestinal  Concretions.  343 

cases,  particularly  in  hysterical  women,  coherent  cy- 
linders of  mucus  are  discharged  in  the  form  of  mem- 
branous casts  of  the  intestine  from  an  inch  to  a  foot 
in  length.  Their  discharge  is  accompanied  by  attacks 
of  colicky  pains  (often  above  the  umbilicus),  distension 
of  the  abdomen  and  an  aggravation  of  the  previously 
existing  obstinate  dyspepsia  (Da  Costa).  The  masses 
are  composed  almost  entirely  of  mucin,  but  sometimes 
of  albumen  and  fibrin  (Whitehead).  In  some  cases 
these  casts  are  formed  in  great  abundance,  and  may 
appear  in  every  stool  for  months ;  but  usually  the 
attack  lasts  only  for  a  few  weeks." '^ 

Dr.  Harleyt  reports  a  case  in  a  woman,  aged 
twenty-eight,  where  symptoms  of  severe  obstruction 
were  caused  by  some  fibrinous  concretions,  four  in 
number,  that  were  finally  discharged  from  the  anus 
with  immediate  relief  to  a  long  continued  train  of 
distressing  symptoms.  One  of  these  masses  measured 
Z\  inches  by  2  inches.  They  were  densely  laminated 
and  fibrous  looking  on  section.  They  appeared  to  be 
composed  merely  of  "lymph."  It  may  be  that  these 
masses  were  thin  "  skin-like  cylinders,"  that  had  been 
long  retained,  had  accumulated  into  masses  and  under- 
gone alteration  in  their  physical  properties. 

M.  Martignon  describes  the  intestine  as  being 
sometimes  blocked  by  a  mass  of  worms  which  forms  a 
definite  tumour  that  is  dull  on  percussion  and  can  be 
felt  through  the  abdominal  parietes.  The  nature  of 
the  mass  he  asserts  can  be  recognised  by  "  une  sorte 
de  mouvement  vermiculaire  sensible  k  la  main."| 
Many  less  recent  writers  describe  this  variety  of  intes- 
tinal obstruction,  and  lay  stress  upon  the  characteristic 
movement  that  can  be  felt  in  the  occluding  mass. 

*  Diseases  of  tlie  Stomach  and  Intestines ;  Ziemssen's  Cyclo- 
paedia,  vol.  vii.,  page  369. 

f  Loc.  cit. 

+  Du  Traitement  de  I'Occlusion  Intestinale  par  le  Morcure 
metalliqne.     Paris,  These,  No.  340,  1879. 


344  Intestinal  Obstruction.      [Chap.  xix. 

I  can  find  no  trustworthy  illustration  of  this  some- 
what improbable  form  of  intestinal  obstruction.  Heller 
in  his  able  monograph  upon  "Intestinal  Parasites"  thus 
refers  to  this  matter:  "The  larger  species  (of  intes- 
tinal worm)  have  been  accused  of  giving  rise  to 
intestinal  obstruction,  being  able,  it  is  said,  when  en- 
tangled into  a  ball,  to  close  mechanically  the  whole 
calibre  of  the  intestine.  Davaine  very  properly 
considers  this  an  erroneous  idea  ;  for  cases  have  been 
known  where  the  intestine  was  literally  crammed 
with  hundreds  of  round  worms,  and  still  the  circu- 
lation of  the  chyme  through  the  interspaces  was  not 
in  the  least  interfered  with."* 


CHAPTER  XIX. 

OBSTRUCTIOX    OF     THE     INTESTINE     BY     F^CAL     MASSES 
CHRONIC  CONSTIPATION — ILEUS    PARALYTICUS. 

Into  the  consideration  of  this  form  of  intestinal 
obstruction,  which  concerns  rather  the  physician  than 
the  surgeon,  it  is  unnecessary  to  enter  at  great  detail. 
It  is  needful  only  to  consider  the  matter  in  so  far  as 
it  concerns  the  diagnosis  of  cases  of  obstruction  of  the 
bowels,  and  in  so  far  as  the  pathology  of  the  affection 
throws  light  upon  the  nature  of  the  other  varieties  of 
occluded  intestine. 

The  morbid  condition  that  forms  the  basis  of  the 
present  form  of  obstruction  is  an  insufficiency  in  the 
forces  that  move  the  intestinal  contents  forwards. 
This  condition  may  pass  on  to  absolute  paralysis  of  a 
segment  of  the  bowel,  leading  to  complete  arrest  of 
the  intestinal  contents  and  sym^^toms  of  obstruction. 

*  Ziemssen's  Cyclopsedia,  vol,  vii.,  i^age  679. 


Chap.  XIX.]         Chronic  Constipation.  345 

In  chronic  constipation  it  can  only  be  said  that  the 
peristaltic  movements  are  very  feeble,  or  are  at  least  in- 
adequate to  accomplish  the  effects  expected  of  them. 
In  ileus  paralyticus,  i.e.  in  the  absolute  obstruction  to 
which  such  constipation  may  lead,  a  considerable 
portion  of  the  bowel  is  incapable  of  any  peristaltic 
movements,  F^cal  matters  collect  in  this  segment 
and  form  a  species  of  plug  which  even  vigorous  action 
in  the  bowel  above  is  not  able  to  dislodge.  The 
retained  f feces  become,  more  and  more  solid  by  absorp- 
tion of  their  fluid  parts,  and  the  intestine  below  the 
obstructed  segment  usually  becomes  contracted,  if  it 
be  empty,  and  so  offers  an  additional  impediment  to 
the  progress  of  the  contents.  As  the  case  progresses 
the  paralysed  intestine  becomes  more  and  more  dis- 
tended, its  muscular  fibres  are  stretched  and  even  rup- 
tured, and  the  possibility  of  a  restoration  of  peristal- 
tic movement  is  rendered  gradually  more  remote. 
The  condition  may  be  further  complicated  by  the 
development  of  chronic  peritonitis  starting  about  the 
paralysed  and  distended  part  of  the  intestine. 

In  the  mucous  membrane  above  the  obstructed  sesf- 
ment  certain  ulcers  may  form,  known  as  stercoral 
ulcers.  These  are  due  partly  to  gangrene  of  the  mu- 
cous membrane  from  pressure,  and  partly  to  the  irri- 
tating and  chemical  effects  of  the  long  retained  and 
altered  faecal  masses.  They  generally  appear  in  the 
form  of  sloughs  of  the  mucous  membrane,  which  may 
extend  until  ulcers  of  large  size  are  produced.  There 
may  be  many  of  such  ulcers.  They  are  most  commonly 
met  with  in  the  csecum,  and  in  the  lower  part  of  the 
ileum.  They  may  lead  to  chronic  peritonitis  or  to 
acute  peritonitis  due  to  perforation,  or  may  in  cicatris- 
ing lead  to  a  stricture  of  the  bowel.  In  some  cases  the 
ulcers  appear  rather  in  a  linear  form  following  the 
transverse  diameter  of  the  bowel,  and  attack  especially 
the  summits  of  the  mucous  folds.     Such  ulcers  may 


346  Intestinal  Obstruction.      [Chap.  xix. 

be  seen  in  both  the  large  and  in  the  small  intestine.  Tlie 
frequent  occurrence  of  stercoral  ulcers  in  tlie  caecum  is 
not  difficult  to  understand. 

Ileus  paralyticus  may  aflfect  both  the  small  and 
the  lar£:e  intestine,  but  it  is  much  more  common  in  the 
latter.  The  ccecum  is  a  part  of  the  colon  where  the 
contents  are  normally  disposed  to  remain  for  some 
time  and  where  they  become  more  solidified.  There 
is  no  doubt  that  in  the  great  majority  of  cases  of  this 
form  of  obstruction  the  valve  remains  efficient.  Fsecal 
matter  cannot  pass  back  from  the  colon  to  the  ileum, 
but  a  vigorous  small  intestine  above  the  valve  may 
continue  to  propel  the  contents  of  the  bowel  in  the 
opposite  direction.  The  cfficum  thus  has  to  bear 
the  brunt  of  internal  pressure  exercised  in  two  direc- 
tions, while  its  shape  and  general  arrangement  make 
it  well  adapted  as  a  receptacle  but  not  as  a  part  for 
resisting  great  strain.  In  cases,  therefore,  where  the 
main  obstruction  has  been  in  the  rectum,  or  in  the 
sigmoid  flexure,  or  in  the  descending  colon,  stercoral 
ulcers  will  most  commonly  be  found  located  in  the 
caecum.  If  not  in  this  part  they  will  be  found  more 
or  less  directly  above  the  seat  of  the  main  ob- 
struction, and  more  especially  in  the  flexures  of  the 
colon. 

The  colon  above  the  main  seat  of  obstruction  may 
become  ruptured  from  distension  without  previous 
ulceration  of  the  mucous  membrane.  This  lesion  is 
most  usually  met  with  at  the  hepatic  or  splenic 
flexures. 

In  distinctly  chronic  cases  the  distension  which 
the  colon  may  undergo  is  enormous.  The  caecum  may 
be  found  almost  as  large  as  an  adult's  head,  the 
sigmoid  flexure  or  the  transverse  colon  may  a]ipear 
to  occupy  the  greater  part  of  the  abdomen,  while  the 
diameter  of  the  distended  bowel  may  attain  to  six, 
eight,  or  ten  inches. 


Chap.  XIX.]         Chronic  Constipation.  347 

The  immense  qnantity  of  f?eces  that  may  accumu- 
late in  such  cases  is  remarkable.  We  read  of  cases 
where  after  death  a  "  bucket-full "  of  faeces  was 
removed  from  the  colon.  Lemazurier  mentions  a 
case  where  a  mass  of  fsecal  matter  weighing  thirteen 
pounds  was  removed  from  the  rectum.  In  an  instance 
reported  by  Renauldin  it  is  said  that  at  the  time  of  the 
patient's  death  sixty  pounds  of  faeces  had  accumulated 
in  the  colon.  Leiciitenstern  in  his  conmients  upon 
this  case  wisely  remarks  that  we  may  entertain 
"  legitimate  doubts  "  of  its  authenticity. 

The  intestine  above  the  obstructed  part  is  apt  to 
become  hypertrophied  in  its  long-continued  attempts 
to  overcome  the  stoppage.  The  hypertrophy  may 
assume  considerable  dimensions.  Thus  in  a  case 
reported  l)y  Dr.  Little  an  idiot,  aged  thirty-four,  died 
of  the  effects  of  long-continued  constipation.  He 
had  possessed  an  enormous  appetite  and  had  been  in 
the  habit  of  eating  great  quantities  of  indigestible 
food.  At  the  autopsy  the  transverse  colon  was  found 
to  be  six  inches  in  diameter,  while  the  descending 
colon  and  sigmoid  flexure  formed  a  huge  pouch 
measuring  twenty  inches  by  twelve  inches.  The 
walls  of  the  sigmoid  flexure  are  said  to  have  been 
from  one-third  to  one-half  of  an  inch  in  thickness."^ 

The  causes  of  chronic  constipation  are  numerous 
and  complex.  Hereditary  influence  has  some  eflect, 
and  in  certain  cases  the  tendency  to  constipation  has 
been  congenital,  f  Exercise  appears  to  assist  the 
action  of  the  bowels,  and  chronic  constipation  is  par- 
ticularly common  in  those  who  lead  sedentary  lives. 
There  are  forms  of  constipation  that  depend  upon  the 
condition  of  the  faeces.  These  matters  may  become 
too  solid,  either  by  the  accumulation  of  much  un- 
digested food  or  by  a  diminution  in  the  amount  of 

*Path.  Soc.  Trans.,  vol.  iii.,  page  106. 

\See  case  by  Dr.  Peacock,  ibid.,  vol.  xxiii.,  page  104. 


34^  Intestinal  Obstruction.      [Chap.xix. 

water  left  unabsorbed  in  the  intestine.  They  may 
moreover,  lose  some  of  the  direct  stimulating  effect 
they  are  supposed  to  exercise  upon  the  intestine,  as  in 
cases  where  they  contain  a  diminished  quantity  of  bile. 
There  are,  again^ forms  of  constipation  that  depend  upon 
nerve  influences,  as  seen  in  the  confined  bowels  of  the 
cachectic,  of  those  suffering  from  certain  brain  and 
cord  affections,  and  in  the  subjects  of  hysteria,  hypo- 
chondriasis, and  idiocy.  Among  other  causes  that 
have  a  more  direct  local  effect  are  the  infiltrations  of  the 
muscular  coat  observed  in  chronic  peritonitis ;  the 
oedema  of  that  tunic  that  may  account  for  the  con- 
stipation in  chronic  Bright's  disease  ;  and  the  injurious 
effect  upon  the  intestinal  wall  of  prolonged  inflam- 
mation, as  seen  in  the  chronic  constipation  tliat  follows 
or  attends  chronic  catarrh.  The  tendency  to  ftecal 
accumulation,  moreover,  may  be  assisted  by  abuor- 
malities  in  the  colon,  by  a  misplaced  c?ecum,  by  an 
abnormally  arranged  transverse  colon,  by  an  unduly 
tortuous  sigmoid  flexure. 

Symptoms. — Obstruction  of  the  bowels  by  fsecal 
accumulation  is  more  common  in  females  than  in 
males,  is  most  frequently  met  with  in  those  who  have 
passed  middle  life,  and  is  very  common  in  the  subjects 
of  hysteria  and  hypochondriasis.  The  patients  are 
liable  to  habitual  and  troublesome  constipation. 
Their  bowels  are  seldom  opened  without  the  aid  of 
aperients  or  enemata.  Many  days  may  elapse  without 
a  stool,  normal  in  amount,  being  passed,  and  from 
time  to  time  enormous  quantities  of  faecal  matter 
will  be  evacuated  by  artificial  aid.  Sometimes  there 
is  a  brief  interlude  of  so-called  diarrhoea.  This 
diarrhoea  is  wholly  spurious.  It  depends  upon 
catarrh  excited  in  the  bowel  above  the  faecal  accumu- 
lation. The  catarrh  causes  a  free  exudation  to  be 
poured  into  the  intestinal  canal,  this  dissolves  a 
certain  amount  of  faecal  matter,  which,  finding  its  way 


Chap.  XIX.]        Chronic  Constipation.  349 

beyond  the  main  mass,  appears  at  the  anus  as  a  slight 
watery  motion. 

In  such  cases  an  examination  of  the  rectum  may 
reveal  the  fact  that  that  gut  is  hlockecl  Ijy  fsecal 
matter.  These  symptoms  may  exist  for  years  without 
causing  more  than  a  little  malaise  or  a  little  digestive 
disturbance,  and  at  no  time  may  severer  abdominal 
disturbances  arise. 

In  more  marked  cases  the  abdomen  becomes  dis- 
tended, evacuations  are  less  frequent  and  more 
difficult  to  obtain.  The  patient  complains  of  a  sense 
of  fulness  and  weight  in  the  abdomen.  His  appetite 
is  poor,  his  tongue  foul,  his  breath  offensive.  He  is 
much  troubled  by  indigestion,  by  distension  after 
food,  by  flatulency,  and  by  eructations,  etc.  He 
not  infrequently  becomes  much  weakened  and  loses 
flesh.  He  may  become  lethargic  and  morose,  or  fret- 
ful and  uneasy,  and  present  some  phase  of  hypo- 
chondriasis. 

If  the  abdomen  become  greatly  distended  other 
symptoms  may  appear.  There  may  be  palpitation,  a 
sense  of  oppression  in  the  chest  and  a  little  dyspnoea 
from  a  pressing  up  of  the  diaphragm  by  the  distended 
bowels.  Pressure  may  be  exercised  upon  the  lumbar 
or  sacral  nerves,  and  the  patient  may  complain  of  dis- 
comfort in  the  genitals,  or  in  the  thigh  (genito-crural 
nerves),  or  down  the  leg  along  some  part  or  parts  of 
the  great  sciatic  nerve.  Or  injurious  pressure  may  be 
exercised  upon  certain  veins ;  upon  the  spermatic 
veins,  producing  varicocele;  upon  the  pelvic  veins, 
causing  piles,  catarrh  or  hypersemia  of  the  uterus ; 
upon  the  iliac  veins,  producing  uncomfortably  cold 
feet  or  even  oedema  of  the  extremities."^ 

The  constipation  may  remain  absolute  for  weeks 
and  months.  All  the  symptoms  may  become  worse. 
The  abdomen  may  become  enormously  distended,  the 
*  See  case,  Path.  Soc.  Trans.,  vol.  xxiii.,  page  104. 


350  Intestinal  Obstruction.      [Chap.  xix. 

apex  of  the  heart  may  be  pushed  up  to  the  third 
intercostal  space, "^  the  distended  coils  may  be  visible 
through  the  thinned  parietes,  and  there  may  be  much 
rumbling  and  gurgling  heard  in  the  abdomen.  When 
in  this  condition  the  patient  has  most  probably  lost 
his  api^etite,  lie  is  troubled  with  frequent  and  foul 
eructations,  he  is  greatly  distressed  by  the  distension 
of  the  abdomen,  he  suffers  from  nausea  and  ultimately 
from  vomiting.  This  vomiting  may  become  feculent. 
But  even  when  the  symptoms  have  advanced  to  an 
extreme  degree,  relief  may  be  afforded  either  by 
enemata  or  by  a  spontaneous  evacuation,  and  after 
the  bowel  has  been  emjDtied  recovery  may  follow.  On 
the  other  hand,  the  case  progresses  from  bad  to  worse, 
the  patient  begins  to  experience  pain  in  the  abdomen, 
or  an  increase  in  the  comparatively  slight  pain  that 
may  have  existed  for  some  time,  he  develops  all  the 
symptoms  of  ileus,  and  dies  of  the  effects  of  the 
unyielding  obstruction. 

In  several  cases  there  has  been  complete  con- 
stipation for  two  or  three  months,  and  the  patient  at 
the  end  of  that  time  has  had  a  relief  of  the  bowels 
and  has  rapidly  recovered.  Mr.  Pollock  reports  the 
case  of  a  lady,  aged  thirty-five,  who  only  had  one 
evacuation  of  the  bowels  every  three  months,  that  is 
to  say,  four  evacuations  in  the  year.f  Dr.  John 
Blake  reports  the  case  of  a  man,  aged  forty-six, 
whose  bowels  were  confined  absolutely  for  eighteen 
weeks.  At  the  end  of  that  time  he  passed  a  motion 
spontaneously,  but  died  within  a  few  days.  Not  the 
least  interesting  fact  in  this  case  is  the  circumstance 
that  an  aspirator-trochar  was  introduced  into  the 
abdomen  of  this  unfortunate  person  no  less  than  150 
times  during  the  continuance  of  the  constipation. 
Before  the  conclusion  of   the  case  the   patient  was 

*Path.  Soc.  Trans.,  vol.  iii.,  page  lOG. 

t  Holmes'  System  of  Surgery,  vol.  ii.,  page  725,  3rd  ed. 


Chap.  XIX.]  Chronic  Constipation.  351 

taking  twelve  grains  of  morphia  a  clay,"'^  In  another 
case,  reported  comparatively  recently,  a  man,  aged 
twenty-six,  who  had  been  always  liable  to  constipa- 
tion, had  at  one  time  no  evacuation  of  any  kind  from 
the  bowels  for  the  almost  incredible  period  of  eight 
montlis  and  sixteen  days,  f  Dr.  Thomas  Strong,  who 
reports  this  case  with  considerable  detail,  alludes  to 
instances  of  patients  who  suffered  from  absolute  con- 
stipation for  periods  respectively  of  seventy-six 
days,  X  fifteen  weeks^  §  seven  months,  ||  eight 
monthSjIT  and  nine  months. "^"^ 

In  another  and  common  class  of  cases  the  patient 
is  liable  from  time  to  time  to  what  may  be  termed 
obstructive  attacks  or  attacks  of  ileus.  In  these 
attacks  it  is  probable  that  the  much  narrowed  canal 
becomes  more  or  less  suddenly  blocked,  whereas  in 
the  previous  class  of  case  the  occlusion  is  brought 
about  by  very  gradual  processes.  The  more  abrupt 
stoppage  may  be  due  to  the  dislodgment  of  a  hard 
mass  of  ftcces ;  or  it  may  depend  upon  bending  or 
kinking  of  the  distended  bowel.  The  latter  condition 
may  be  met  with  in  the  transverse  colon  and  in  the 
sigmoid  liexure,  and  especially  at  the  point  of  junction 
of  the  flexure  with  the  rectum. 

A  patient,  therefore,  who  has  presented  for  months 
the  symptoms  of  chronic  constipation  may  be  more  or 
less  suddenly  attacked  with  severe  colicky  pains  in  the 
abdomen.  Associated  with  this  symptom  are  absolute 
constipation,  increased  distension  of  the  abdomen,  and 
very  probably  tenesmus.     The  patient  is  troubled  by 

*  Boston  Med.  and  Sury.  Jo  urn.,  vol.  xiv.,  Nov.,  1876,  page 
601. 

fAmer.  Journ.  of  Med.  Sc,  vol.  Ixviii.,  1874,  page  440. 

i North  Amer.  Med.  and  Surg.  Journ.,  vol.  iv.,  page  262. 

§  Dr.  Baillie,  Trans,  of  a  Soc.  for  the  Promoting  of  Med.  and 
Chir.  Knowledge,  vol.  ii. ,  page  174. 

jl  Staniland;  Lond.  Med.  Gazette,  vol.  xi.,  page  245. 

"if  Dr.  Crampton;  Dublin  Hosp.'  Reports,  vol.  iv.,  page  30.3. 

**Dr.  Valentine;  Bull,  dcs  Sc.  IMdd.,  tome  x.,  page  74. 


352  Intestinal  Obstruction.       [Chap. xix. 

nausea  and  foul  eructations,  and  soon  begins  to  vomit. 
The  vomiting  is  not  so  easily  established  as  it  is  in 
some  of  the  other  of  the  less  chronic  varieties  of  ob- 
struction, nor  is  it  usually  very  severe.  It  may, 
however,  become  feculent.  All  the  symptoms  are 
commonly  aggravated  by  taking  food.  Coils  of  in- 
testine may  be  visible,  and  more  or  less  constant  bor- 
borygmi  will  be  heard  in  the  abdomen.  The  symptom 
may  become  worse,  and  worse  and  the  patient  may 
finally  die  of  exhaustion. 

Before  death  he  may  or  may  not  have  developed 
evidences  of  peritonitis. 

The  first  of  these  attacks  may  prove  fatal ;  but 
such  an  occurrence  is  very  rare.  As  a  rule,  the 
patient  has  many  obstructive  attacks,  which  pro- 
bably increase  in  severity  as  time  advances.  These 
attacks  may  last  from  three  and  four  to  ten  and 
fifteen  days,  may  be  associated  with  feculent  vomiting, 
and  may  be  at  last  relieved  either  spontaneously,  or 
by  the  use  of  aperients  and  eneraata.  An  enema, 
whether  it  at  once  produce  an  evacuation  or  not^  is 
often  followed  by  an  improvement  in  the  symptoms 
for  a  while. 

In  all  cases  of  obstruction  by  faecal  masses,  no 
matter  what  may  be  their  particular  clinical  aspect, 
there  is  very  usually  present  a  diagnostic  feature  of 
much  importance  to  which  allusion  has  not  y^t  been 
made.  I  refer  to  a  tumour  formed  by  the  mass  of 
retained  foeces. 

In  the  somewhat  uncommon  cases  where  the 
obstruction  concerns  the  small  intestine  only  no 
tumour  will  probably  be  detected.  The  distension  of 
the  abdomen  will  mainly  concern  the  umbilical,  hy})0- 
gastric,  and  epigastric  regions,  while  the  district  of  the 
colon  will  reveal  upon  examination  a  more  or  less 
empty  state  of  the  bowel.  It  is  when  the  obstruction 
depends  upon  the  impaction  of  fiecal  masses  in  tlie 


Chap.  XIX.]         Chronic  Constipation.  353 

colon  that  the  f cecal  tumour  is  most  distinctly  met 
with.  This  tumour  is,  as  a  rule,  most  readily  to  be 
felt  in  the  ca3cum.  The  caecum,  it  is  needless  to  say, 
occupies  the  right  iliac  fossa  in  such  a  way  that  its 
extremity  reaches  nearly  to  the  middle  of  Poupart's 
ligament.  The  faecal  mass,  therefore,  will  correspond 
to  the  outer  half  of  the  ligament.  Such  tumours 
feel  hard  and  uneven,  are  of  a  globular  shape,  and 
are  as  a  rule,  painless.  Sometimes,  however,  the 
region  of  the  tumour  is  the  seat  of  much  pain  and 
tenderness,  a  circumstance  that  probably  depends 
upon  a  little  local  peritonitis.  In  the  ascending  colon 
the  tumour  will  possibly  feel  softer,  will  be  cylin- 
drical in  outline  and  very  like  a  chronic  intussus- 
ception, especially  as  its  limits  cannot  be  usually  well 
defined. 

Masses  in  the  transverse  colon  may,  when  near 
the  hepatic  flexure,  give  rise  to  the  impression  that 
the  liver  is  enlarged,  the  extent  of  dulness  over  that 
viscus  being  increased.  These  tumours,  when  in  a 
mobile  part  of  the  colon,  are  of  course  themselves 
movable.  Masses  in  the  transverse  colon  may  cause 
the  gut  to  become  bent  down,  and  the  fsecal  tumour 
therefore  has  in  such  cases  been  felt  near  to  the  sym- 
physis. When  in  the  descending  colon  or  sigmoid 
flexure  the  f?ecal  mass  will  usually  feel  harder  and  its 
division  into  scybala  may  be  detected.  Indeed, 
tumours  in  this  situation  have  been  compared  to  a 
large  rosary  on  account  of  their  uneven  and  nodular 
surface. 

In  thin  individuals  and  in  others,  when  under  an 
ana3sthetic,  the  softer  of  these  fsecal  masses  may  be 
affected  by  pressure  and  may  give  to  the  fingers  the 
reaction  of  a  mass  of  dough  or  of  putty.  When 
such  a  character  is  presented  by  the  tumour  the  dia- 
gnosis of  its  nature  is  placed  beyond  doubt. 

Faecal  tumours  may  exist  unchanged  for  weeks  or 
x-12 


354  Intestinal  Obstruction.      [Chap.  xix. 

montliS;  and  may  coincide  with  the  passage  of  normal 
motions  or  with  the  spurious  diarrhoea  to  which 
attention  has  ah^eady  been  directed. 

These  tumours  have  been  mistaken  for  cancer,  for 
chronic  intussusception,  for  tumours  of  the  liver, 
stomach,  spleen,  and  kidneys,  for  ovarian  and  otlier 
pelvic  tumours,  and  for  pregnancy.  The  great  disten- 
sion of  the  abdomen  and  the  presence  of  much  flatus 
within  the  intestine  in  these  cases  are  apt  to  obscure 
the  details  of  the  mass  when  it  exists. 

In  a  case  of  obstruction  from  impacted  fjeces 
brought  before  the  notice  of  the  Sheffield  Medico- 
Chirurgical  Society*  by  Dr.  Thomas,  it  is  stated  that 
after  aperients  had  been  administered  and  massage 
applied,  "  the  sound  of  the  moving  faeces  was  heard 
with  the  stethoscope."  This  experience  is,  so  far  as  I 
am  aware,  unique. 

With  regard  to  the  prognosis  in  this  form  of  ob- 
struction it  may  be  said  to  be,  upon  the  whole,  good. 
Patients  may  present  the  symptoms  of  chronic  con- 
stipation through  the  greater  part  of  a  lifetime.  In 
the  obstructive  attacks  also,  no  matter  whether  of 
gradual  or  of  abrupt  development,  a  termination  by 
relief  is  more  frequent  than  a  termination  by  death. 
At  the  same  time  it  must  be  noted  that  the  longer  the 
morbid  condition  persists,  and  the  more  frequent  the 
attacks  of  ileus  become,  the  more  grave  is  the  pro- 
gnosis. 

The  causes  of  death  in  these  cases  are  numerous. 
The  patient  may  die  exhausted  by  prolonged  obstruc- 
tion with  its  attendant  effects  upon  the  digestion  and 
general  nutrition.  He  may  die  of  rupture  or  perfora- 
tion of  the  distended  bowel,  or  of  chronic  peritonitis, 
or  of  stricture  following  the  healing  of  a  stercoral 
ulcer,  or  of  obstruction  depending  upon  adhesions  due 
to  a  previous  chronic  peritonitis.  In  the  more  rapid 
*  Brit.  Med.  Journ.,  Jan.  5,  1884,  page  12. 


Chap.  XX.]        The  Symptoms:  Collapse,  355 

cases  he  may  die  of  acute  obstruction  depending  upon 
sudden  blocking  of  the  bowel,  or  upon  acute  bending 
or  kinking  of  the  elongated  intestine,  or  upon  a 
volvulus  of  the  distended  and  tortuous  sigmoid 
flexure.  The  dependence  of  volvulus  of  the  sigmoid 
flexure  upon  chronic  constipation  has  been  already 
pointed  out. 


CHAPTER    XX. 

THE    DIAGNOSIS. 

The  important  and  complicated  subject  of  the  dia- 
gnosis of  the  various  forms  of  obstruction  of  the 
intestine  may  be  most  conveniently  considered  under 
the  following  headings  : 

1.  The  general  significance  of  the  leading  symp- 
toms. 

2.  The  diagnosis  of  the  different  forms  of  intes- 
tinal obstruction. 

3.  The  symptoms  as  modified  by  the  position  of 
the  obstruction. 

4.  The  various  affections  that  have  been  most 
frequently  confused  with  cases  of  obstruction  of  the 
bowels. 

THE   GENERAL    SIGNIFICANCE    OF    THE    LEADING 
SYMPTOMS. 

Collapse. — The  marked  and  often  severe  de- 
gree of  shock  observed  in  cases  of  acute  obstruction 
does  not  depend  obviously  upon  the  mere  abrupt 
occlusion  of  the  intestine,  but  upon  the  sudden 
damage  inflicted  upon  the  peritoneum  and  intestinal 
walls  by  the  strangulating  agent.  Shock  in  these 
cases  is  indeed  precisely  of  the  same  nature  as  that 


356  Intestinal  Obstruction.        [Chap.  xx. 

that  attends  wounds  and  other  injuries  to  the  abdo- 
men and  as  that  that  results  from  the  perforation  of 
an  ulcer  of  the  stomach  or  intestine.  Into  the 
physiological  processes  involved  in  the  production  of 
the  symptoms  of  collapse  it  is  not  necessary  here  to 
enter.  The  matter  has  been  well  and  fully  investi- 
gated by  means  of  vivisection  experiments,  and  has 
been  illustrated  by  the  effects  of  injury  and  dis- 
ease occurring  in  the  human  subject.  It  has  been 
shown  that  the  manifestations  of  collapse  depend 
upon  a  profound  impression  upon  the  nervous  sys- 
tem, an  impression  that  acts  mainly  through  the 
sympathetic  centres  and  displays  itself  through  cer- 
tain grave  and  violent  vascular  disturbances.  The 
altered  circulatory  conditions  are  made  evident  by  the 
lowering  of  the  temperature  of  the  surface,  by  the 
cold  sweats,  by  the  frequent  lividity  of  the  extremities, 
by  the  anaemia  of  the  brain,  by  the  small  and  rapid 
pulse. 

The  degree  of  the  collapse  depends  mainly  upon 
three  circumstances  :  upon  the  disposition  of  the 
patient,  upon  the  suddenness  of  the  strangulation, 
and  upon  the  amount  of  peritoneum  or  of  intestine 
involved  in  the  lesion.  This  symptom  is  usually  most 
marked  in  cases  of  acute  obstruction  occurring  in  the 
very  J^oung  or  in  the  very  old,  although  at  the  same 
time  it  must  be  allowed  that  some  of  the  most  pro- 
found cases  have  been  met  with  in  adults  about 
middle  life. 

Those  instances  of  collapse  in  intestinal  obstruc- 
tion of  so  grave  and  abiding  a  nature  as  to  cause  the 
patient's  condition  to  be  mistaken  for  cholera  have 
mostly  occurred  in  vigorous  adults  in  the  prime  of 
life.  Such  individuals  are,  from  the  very  activity  of 
their  bodily  processes,  capable  of  presenting  Adolent 
forms  of  strangulation,  wherein  the  lesion  to  the  peri- 
toneum outweighs  the  matter  of  age  as  a  factor  in  the 


Chap. XX.]  The  Symptoms:  Pain.  357 

production  of  collapse.  It  is  certain  also  that  the 
degree  of  the  collapse  depends  much  upon  individual 
peculiarities,  just  as  different  individuals  may  present 
different  capacities  for  enduring  pain. 

As  regards  the  local  conditions,  the  gravest  amount 
of  shock  is  met  Avitli  in  cases  where  a  considerable 
segment  of  the  intestine  is  suddenly  strangulated,  and 
an  injury  is  thus  abruptly  inflicted  upon  an  extensive 
nerve  area. 

It  will  be  readily  understood  that  this  symptom 
is  more  usually  associated  with  strangulation  of  the 
small  intestine  than  with  that  of  the  large.  This 
depends  not  only  upon  the  circumstance  that  the  small 
intestine  is  the  part  more  commonly  involved  in  acute 
obstruction,  but  also  upon  the  more  direct  association 
of  the  nerves  of  the  upper  segment  of  the  bowel  with 
the  great  sympathetic  ganglia  of  the  abdomen.  This 
matter  will  be  again  referred  to  in  a  subsequent 
paragrajDh, 

Pain. — This  symptom,  which  is  so  conspicuous  a 
feature  in  intestinal  obstruction,  depends  upon  several 
conditions.  It  is  due,  in  the  first  instance,  to  the 
lesion  experienced  by  the  peritoneum  and  by  the 
intestinal  walls  as  a  result  of  the  strangulation.  It 
depends  at  a  somewhat  later  period,  or  in  the  first 
instance  in  certain  cases,  upon  the  tumultuous  and 
irregular  peristaltic  movements  excited  in  the  intestine. 
These  movements  are  more  or  less  arrested  at  the  seat 
of  obstruction,  and  the  peristaltic  wave,  no  longer 
moving  regularly,  leads  to  disordered  muscular  con- 
tractions that  are  the  basis  of  the  symptoms  known  as 
"  colic."  There  is  no  doubt  that  by  the  undue  reflex 
action  excited  by  the  peritoneal  lesion,  and  by  the 
actual  obstruction,  the  movements  in  the  bowel  above 
the  occlusion  become  unusually  vigorous.  The  perio- 
dical exacerbations  of  pain  are  due  to  the  passage 
along  the  intestine  of  periodic  peristaltic  waves  that 


358  Intestinal  Obstruction.       [Chap.  xx. 

hurl  themselves,  as  it  were,  against  the  obstruction. 
This  circumstance  can  often  be  well  displayed  in 
chronic  cases  associated  with  emaciation  and  with 
visible  movement  of  the  intestinal  coils. 

The  intensity  of  the  pain  depends  upon  the  ex- 
citability of  the  individual,  upon  the  state  of  the 
sensorium,  upon  the  extent  of  intestine  and  peritoneum 
involved,  and  upon  the  severity  and  abruptness  of  the 
occluding  lesion.  As  time  advances  the  nature  of  the 
pain  is  influenced  by  the  distension  of  the  gut  and 
by  the  appearance  or  non-appearance  of  peritonitis. 

In  the  matter  of  diagnosis,  I  would  call  especial 
attention  to  a  feature  in  the  character  of  the  pain 
that  has,  so  far  as  I  am  aware,  not  attracted  notice. 
It  is  this.  In  cases  where  the  obstruction  is  complete 
the  pain  is  constant,  although  liable  to  periodic  exacer- 
bations. In  cases  where  the  obstruction  is  but  partial 
the  pain  is  distinctly  intermittent,  and  the  individual 
experiences  intervals  between  attacks  of  pain  during 
which  he  is  free  from  suffering. 

To  this  rule  I  have  been  able  to  find  extremely 
few  exceptions  that  may  be  regarded  as  satisfactory. 
As  illustrations  of  the  relationship  I  might  draw 
attention  to  the  constant  pain  in  acute  strangulation 
as  compared  with  the  markedly  intermittent  pain  in 
stricture.  If  in  a  case  of  stricture  the  stenosed  seg- 
ment become  suddenly  occluded  the  nature  of  the  pain 
will  change  almost  as  suddenly  and  will  become  con- 
tinuous where  before  it  was  purely  intermittent. 

Moreover,  one  observes  in  cases  of  stricture  that 
as  the  malady  advances,  and  as  the  narrowed  part  be- 
comes still  more  narrow,  so  does  the  pain  appear  at 
less  lengthy  intervals,  until  at  last,  when  the  intestine 
has  become  entirely  occluded,  the  pain  will  have 
become  also  more  or  less  continuous.  In  intussus- 
ception, again,  the  early  pain  is  usually  characterised 
by   its   distinctly   intermittent    character ;    and   tliis 


Chap.  XX.]  The  Symptoms:  Pain.  359 

character  it  maintains  wliilc  the  lumen  of  the 
invaginated  part  remains  patent,  and  while  the  patient 
evacuates  bloody  stools.  On  the  occurrence,  however, 
of  complete  obstruction,  the  character  of  the  pain 
changes,  and  the  suffering  experienced  by  the  patient 
is  continuous,  although  aggravated  by  periodic  exacer- 
bations. 

I  would  urge,  therefore,  that  in  the  diagnosis  of 
cases  of  intestinal  obstruction,  very  particular  atten- 
tion should  be  paid  to  the  nature  of  the  pain,  and 
especially  to  the  length  of  the  intervals  of  ease  that 
occur  in  instances  of  intermittent  pain. 

In  examples  of  intermittence,  many  of  the  recorded 
cases  that  I  have  collected  show  that  the  duration  of 
the  attacks  of  pain  is  apt  to  increase  as  the  duration 
of  the  interval  of  ease  diminishes. 

The  pain  in  the  earlier  stages  of  intestinal  ob- 
struction is  usually  not  aggravated  by  pressure.  It  is 
unassociated,  in  fact,  with  tenderness,  and  is,  indeed, 
very  often  much  relieved  by  compression  of  the  abdo- 
men. The  appearance  of  tenderness  is  coincident  with 
great  hyperasmia  of  the  peritoneum,  or  with  actual 
peiitonitis. 

The  diminution  in  the  severity  of  the  pain  that  is 
not  infrequently  experienced  towards  the  termination 
of  a  fatal  case  may  depend  upon  the  colla})se  following 
perforation,  or  upon  diminished  activity  of  the  senso- 
rium,  or  upon  extensive  paralysis  of  the  intestine  as  a 
result  of  peiitonitis,  or  upon  a  rupture  or  perforation 
of  the  bowel  into  some  part  other  than  the  peritoneal 
cavity. 

T'he  great  increase  in  the  pain  that  is  often  expe- 
rienced after  food,  or  after  the  use  of  enemata,  or  even 
after  digital  examination  of  the  rectum,  depends  upon 
increased  reflex  action  and  the  fresh  peristaltic  move- 
ment tliat  it  excites. 

In  one  or  two  cases  a  rectal  exploration  induced 


360  Intestinal  Obstruction.        [Chap.  xx. 

very  violent  attacks  of  pain  in  examples  of  obstruction 
of  the  small  intestine. 

With  regard  to  the  situation  of  the  pain,  as  dis- 
tinguished from  tenderness,  I  would  decidedly  dissent 
from  the  statements  of  the  somewhat  numerous 
authors  who  assert  that  it  corresponds  to  the  seat  of 
the  obstruction.  In  the  case  of  the  small  intestines, 
I  am  convinced,  not  only  that  the  situation  of  the  pain 
is  of  no  value  in  diagnosing  the  site  of  the  occlusion, 
but  that  it  is,  if  used  for  such  diagnostic  i3urposes, 
absolutely  misleading.  In  the  development  of  the 
human  intellect,  the  factors  upon  which  an  apprecia- 
tion of  position  and  distance  are  founded  are  tolerably 
well  known  and  allowed.  These  factors  are  constant. 
The  child  gradually  acquires,  by  slow  experience,  a 
knowledge  of  the  localisation  of  sensation  ui3on  various 
parts  of  its  integument.  There  is  probably  a  period 
in  its  existence  when  painful  sensations  are  appre- 
ciated solely  by  their  degree  or  quality  without  any 
reference  to  locality.  It  is  a  matter  of  gradual  expe- 
rience to  distinguish  a  pain  on  the  back  of  the  hand 
from  one  on  the  back  of  the  shoulder.  The  factors 
upon  which  that  experience  is  founded  are  constant. 
The  distances  between  the  two  painful  spots  are  con- 
stant, and  can  be  appreciated  by  sight  as  well  as  by 
feeling.  It  is  by  an  unconscious  j)rocess  of  repeated 
comparison  that  a  child  acquires  a  knowledge  of  its 
own  skin,  or  of  its  own  skin  so  far  as  it  is  concerned 
as  a  vehicle  for  sensation.  With  resrard  tolthe  locali- 
sation  of  sensation  in  the  intestine  (and  we  will 
consider  particularly  the  small  intestine),  it  must  be 
remembered  tliat  the  length  of  the  bowel  is  very  con- 
siderable ;  that  the  coils  are  perpetually  changing  their 
position  and  altering  the  mutual  relation  they  bear  to 
one  another  ;  and  that  the  part  is  not  very  directly 
supplied  with  spinal  nerves.  Without  discussing  the 
subject  at  greater  length,  I  think  it  will  be  evident 


Chap.  XX.]  The  Symptoms  :  Pain.  361 

that  the  small  intestine  at  least  does  not  possess  that 
arrangement  of  parts  which  we  are  apt  to  regard  as 
essential  for  the  proper  localisation  of  sensations  pain- 
ful or  otherwise.  The  j.iassage  of  a  large  foreign  body- 
along  the  lesser  bowel  is  often  associated  with  great 
and  long-continued  pain.  But  neither  the  nature  nor 
the  position  of  the  pain  appears  to  be  in  any  way 
modified  by  the  localisation  of  the  intruding  substance. 
If  the  passage  along  the  intestine  of  a  foreign  body, 
capable  of  exciting  pain  throughout  its  whole  progress, 
were  a  matter  of  daily  occurrence,  then  in  time  it 
may  be  possible  for  an  individual  to  localise  painful 
sensations  in  certain  vague  segments  of  the  gut ;  but 
even  such  an  experience  could  never  enable  any  one 
to  localise  a  pain  in  one  very  limited  portion  of  a  tube 
that  is  many  feet  in  length.  In  speaking  of  the 
symptom  of  pain  in  connection  with  the  subject  of 
strangulation  by  bands  (page  73),  I  have  pointed 
out  that  no  matter  in  what  part  of  the  small  intes- 
tine the  obstruction  is  situated,  the  pain  arising  there- 
from is  very  usually  referred  to  the  region  of  the 
umbilicus. 

A  little  way  above  the  umbilicus  is  situated  the 
solar  plexus,  and  it  is  to  this  centre  that  the  pain  is,  I 
think,  referred.  In  the  paragraph  above  alluded  to,  I 
have  given  many  examples  to  show  the  want  of  definite 
connection  between  the  seat  of  pain  and  the  seat  of 
the  lesion  that  caused  it. 

In  the  case  of  the  stomach  and  of  the  colon  it  is 
possible  to  conceive  that  painful  sensations  occurring  in 
those  parts  may  be  more  or  less  definitely  localised, 
since  they  are  more  constant  in  position  and  in  the 
relation  that  their  parts  bear  to  one  another.  The 
position  of  the  pain  in  gastric  ulcer,  and  in  some  cases 
of  cancer  of  the  large  intestine,  would  appear  to  sup- 
port this  notion,  although  in  the  great  majority  of 
the  cases  of  stricture  of  the  colon  the  situation  of  the 


362 


Intestinal  Obstruction.        iChap.  xx. 


pain  has  been  of  no  value  in  diagnosing  the  position 
of  the  stenosis. 

Toinitiiig'. — Vomiting  in  cases  of  intestinal  ob- 
struction is  mainly  due  to  peristaltic  action.  The 
bowel  becomes  occluded  at  a  certain  point.  Above 
that  point  the  contents  of  the  tube  collect,  and 
some  dilatation  of  the  bowel  from  distension  takes 
place.  A  wave  of  peristaltic  movement  passing 
along  the  intestine  above  the  occluded  part  will  tend 
to  induce  two  distinct  currents  in  the  contents  of  the 
tube,  in  the  place  of  the  single  current  in  the  direction 
of  the  rectum  that  is  the  result  of  peristalsis  under 
normal  circumstances.  One  of  these  movements  is  in 
the  downward  direction  and  concerns 
such  of  the  contents  as  are  nearer  to  the 
wall  of  the  intestine.  The  other  is  an 
upward  movement  that  concerns  the  con- 
tents occupying  the  axial  part  of  the 
bowel.  This  axial  current,  in  the  upward 
direction,  is  the  direct  result  of  the  ob- 
struction offered  to  the  passage  of  matters 
along  the  intestine.  Dr.  Brinton,  who 
first  drew  attention  to  this  subject  in  his 
well-known  monograph,  illustrates  the 
double  current  by  the  action  of  a  piston, 
perforated  in  the  centre,  as  it  passes 
along  a  tube  closed  at  one  extremity 
(Fig.  56).  He  further  pointed  out  that  a 
series  of  such  pistons  passing  down  the 
tube  one  after  the  other  would  tend  to 
indefinitely  lengthen  the  upward  axial 
current  and  render  it  perfectly  con- 
tinuous. 

Dr.  Brinton  also  showed  that  the  dis- 
tended segment  of  intestine  immediately  above  the 
obstruction  would  be  ])ractically  unaffected  by  the 
peristaltic  movements,  and  would  have  the  effect  of 


' 


5U. 


Chap.  XX.]       The  Symptoms  :    Vomiting.  363 

placing  the  starting  point  of  the  upward  axial  move- 
ment hio-her  and  hisiher  in  the  intestine  as  the  accumu- 
lation  increased. 

This  latter  circnmstance,  however,  is  by  no  means 
necessary  for  the  complete  demonstration  of  Dr. 
Brinton's  theory  of  the  emptying  of  the  intestinal 
contents  into  the  stomach  by  no  other  motor  power 
than  the  peristaltic  movements  of  the  bowel  itself. 
As  a  matter  of  fact,  however,  there  is  more  than  one 
factor  concerned  in  the  evacuation  upwards  of  the 
intestinal  contents.  When  the  bowel  above  the 
occlusion  has  become  filled  by  gradual  accumulation 
of  its  contents,  its  degree  of  distension  may  be  such 
that  all  pressure  brought  to  bear  upon  the  bowel  so 
occupied  can  do  no  other  than  force  the  contents  in 
the  only  direction  in  which  they  can  go,  viz.  towards 
the  stomach.  This  pressure  may  be  exercised  during 
every  act  of  vomiting,  every  contraction  of  the 
diaphragm  or  of  the  abdominal  muscles,  and  even  by 
the  mutual  pressure  that  the  distended  coils  would 
exercise  the  one  upon  the  other. 

It  will  be  obvious  that  the  more  fluid  the  contents 
of  the  intestine  the  more  easily  will  they  be 
evacuated,  and  that  ready  and  early  vomiting  is  more 
likely  to  occur  when  the  obstruction  is  near  the  upper 
than  when  it  is  near  the  lower  segment  of  the 
bowel. 

It  is  impossible  to  discuss  this  subject  without 
some  reference  to  the  question  of  antiperistalsis, 
which  was  at  one  time  accredited  with  beino-  the 
main  cause  of  stercoraceous  vomiting.  That  anti- 
peristaltic movements  occur  in  the  intestine  has  been 
placed  beyond  doubt  by  numerous  observers.  These 
movements  have  been  seen  also  in  cases  of  artificial 
obstruction  of  the  bowels  induced  in  animals.  There 
is,  however,  not  the  least  evidence  to  show  that  anti- 
peristalsis  is  absolutely  essential  for  the  propelling  of 


364  Intestinal  Obstruction.       [Chap.  xx. 

the  intestinal  contents  towards  the  stomach,  much 
less  that  it  is  the  main  cause  of  stercoraceous  vomiting. 
These  movements,  when  observed,  have  been  feeble, 
imperfect,  and  irregular,  and  of  comparatively  little 
significance  by  the  side  of  the  tumultuous  peristaltic 
movements  passing  in  the  usual  direction. 

As  Dr.  Brinton  has  well  observed,  if  antijDeristalsis 
were  the  cause  of  the  stercoraceous  vomiting,  then 
would  one  expect  to  find  at  an  autopsy  the  gut  above 
the  obstruction  empty  and  contracted,  while  the 
intestine  nearer  to  the  stomach  would  be  in  a  state  of 
distension.  It  is  needless  to  say  that  the  reverse  is 
what  is  found.  In  many  cases,  moreover,  metallic 
mercury,  and  other  substances  introduced  into  the 
stomach  before  death,  have  been  found  in  the 
autopsy  to  have  traversed  the  whole  length  of  the 
intestine  as  far  as  the  obstruction,  in  spite  of  severe 
feculent  vomiting  during  life.  Leichtenstern,  who  is 
entirely  opposed  to  the  theory  of  antiperistalsis  as 
a  factor  in  stercoraceous  vomiting,  mentions  the 
following  as  the  only  facts  that  appear  to  favour  such 
a  theory  :  "1st.  Those  veiy  rare  cases  in  which  sterco- 
raceous vomiting  is  observed  in  the  course  of  a  diffuse 
peritonitis  without  demonstrable  alteration  of  the 
permeability  of  the  intestine.  2nd.  The  fact  that  in 
cases  of  acute  internal  incarceration  the  stercoraceous 
vomiting  occurs  only  a  few  hours  after  the  beginning 
of  the  attack,  at  a  time  when  it  cannot  well  be  thought 
that  there  is  any  great  accumulation  of  intestinal 
matter.  3rd.  The  movements  of  the  intestine  in 
cases  of  inflammation  and  other  irritations  of  the 
peritoneum,  differ,  so  far  as  their  quality  and  effects 
are  concerned,  from  what  is  normal."  With  regard 
to  the  first  "  fact,"  it  must  be  noted  that  in  peri- 
tonitis a  large  segment  of  the  intestine  may  remain 
for  a  long  time  non-paralysed.  The  accumulation  of 
intestinal  contents   in  the   paralysed  segment  would 


Chap.  XX.]       The  Symptoms:   Vomiting.  365 

constitute  a  definite  obstruction,  and  if  the  non- 
paralysed  part  consisted  of  a  continuous  portion  of 
the  bowel  extending  from  the  stomach  to  the  involved 
segment  the  very  condition  for  the  evacuation  of  the 
intestinal  contents  would  be  established.  With  regard 
to  the  second  fact,  stercoraceous  vomiting  within 
a  few  hours  after  the  occurrence  of  strangulation 
is  extremely  rare,  and  it  has  yet  to  be  shown  that 
a  certain  accumulation  of  matters  in  the  bowel  is 
needful  for  the  production  of  stercoraceous  vomiting. 
The  third  fact  to  be  of  any  value  must  prove  that  the 
abnormal  movements  are  in  the  inverted  direction 
and  are  of  sufficient  extent  and  of  sufficient  duration 
to  move  the  contents  of  the  tube  (without  other 
assistance)  in  the  direction  of  the  stomach. 

In  stercoraceous  vomiting  the  matter  is  derived 
from  the  lower  ileum  or  from  the  colon.  It  has  been 
most  conclusively  shown  that  for  the  production  of 
feculent  vomiting  it  is  by  no  means  necessary  to 
assume  that  matter  regurgitates  from  the  colon  into 
the  ileum  through  the  ileo-caecal  valve.  The  contents 
of  the  lower  ileum  have  often  the  distinct  characters 
of  soft  faecal  matter  in  normal  circumstances,  and 
when  retained  in  a  disordered  and  obstructed  intes- 
tine it  is  not  difficult  to  understand  that  they  may 
soon  acquire  those  characters  from  decomposition, 
even  if  they  did  not  originally  possess  them.  At  the 
same  time  it  is  now  fully  allowed  that  the  ileo-csecal 
valve  may  become  insufficient  during  life  and  may 
permit  faecal  matter  to  regiu-gitate  from  the  colon 
into  the  lesser  bowel. 

This  insufficiency  may  be  met  with  in  great 
distension  of  the  caecum  and  ileum  associated  with 
paralysis  of  the  parts  concerned  in  the  valve.  Tlie 
occurrence,  however^  of  this  insufficiency  is  certainly 
very  uncommon,  as  is  proved  by  repeated  examinations 
of  the  parts  after  death  from  stricture  of  the  colon. 


366  Intestinal  Obstruction.        tchap.  xx. 

When  the  obstruction  occupies  the  lower  duodenum 
or  jejunum  the  vomited  matters  are  usually  very 
copious  and  always  deeply  stained  by  bile.  They  can 
never  become  really  stercoraceous,  although  if  long 
retained  they  may  become  discoloured  and  acquire  so 
offensive  a  smell  as  to  be  possibly  mistaken  for  fecu- 
lent matters.  In  the  same  way  the  vomiting  in 
examples  of  obstruction  in  the  middle  of  the  ileum 
can  never  be  stercoraceous  in  the  strict  sense  of  the 
term.  If,  however,  the  contents  of  the  bowel  have 
been  long  retained,  as  in  cases  where  the  vomiting 
has  been  subdued  by  opium,  then  they  may  become 
so  altered  from  decomposition  as  to  have  a  feculent 
odour. 

In  some  cases  the  stercoraceous  vomiting  has  been 
due  to  a  fistula  bimucosa  between  the  colon  and  the 
upper  part  of  the  small  intestine,  as  occurred  in  a  case 
reported  by  Mr.  Shaw."^ 

As  already  remarked,  the  main  part  of  the 
vomiting  in  cases  of  intestinal  obstruction  no  doubt 
depends  upon  peristaltic  action  taking  place  under 
peculiar  conditions.  This  is,  however,  not  the  only 
cause,  nor  is  it  obviously  the  cause  of  the  initial  vomit- 
ing in  acute  strangulation. 

This  initial  vomiting  is  due  to  the  damage  inflicted 
upon  the  peritoneal  and  intestinal  nerves  by  the  stran- 
gulation. It  is  a  purely  reflex  act,  and  of  precisely  the 
same  nature  as  the  vomiting  that  may  follow  a  wound 
of  the  abdomen  or  a  crush  of  tlie  testicle.  The  more 
excitable  the  reflex  centres  the  more  readily  is  the 
vomiting  induced.  It  thus  occurs  peculiarly  early  in 
children  and  in  delicate  and  unduly  sensitive  women. 
Since  the  nerve  supply  of  the  lesser  intestine  is  more 
liberal  and  more  directly  connected  with  the  great 
abdominal  plexuses  than  is  tliat  of  the  colon,  it  may  be 
surmised  that  lesions  involving  the  former  segment  of 
*Patli.  Soc.  Trans.,  vol.  iv.,  page  147. 


Chap.  XX.]       The  Symptoms  :   Vomiting.  367 

the  bowel  will  be  more  rapidly  followed  by  sickness 
than  will  those  implicating  the  large  intestine. 

The  dependence  of  much  of  the  vomiting  upon  reflex 
nerve  disturbance  is  illustrated  by  cases  of  ]:»seudo- 
strangulation,  by  cases  where  vomiting  in  instances 
of  intestinal  obstruction  has  been  excited  by  explora- 
tion of  the  rectum,  and  by  the  close  association  of  the 
symptom  with  the  symptom  of  pain. 

One  of  the  best  illustrations,  however,  of  the 
possible  independence  of  vomiting  in  intestinal  cases 
of  peristalsis  is  afforded  by  casual  vomiting  in  indi- 
viduals with  an  artificial  anus.  Thus  Mr.  Bryant 
reports  a  case  of  intestinal  obstruction  for  which  he 
performed  enterotomy,  leaving  a  permanent  artificial 
anus  connected  with  the  small  intestine.  The  patient 
was  at  a  subsequent  period  much  troubled  by  the 
fseces  that  had  been  retained  in  the  colon  below  the 
abnormal  opening,  and  that  were  unable  to  escape. 
The  irritation  of  these  masses  induced  much  abdo- 
minal pain  and  vomiting.  The  interruption  of  the 
intestine  between  the  obstructing  masses  and  the 
stomach  afforded  by  the  artificial  anus  must  have 
prevented  peristaltic  movement  from  taking  any 
dii'ect  share  in  the  production  of  the  vomiting.* 

In  those  cases  where  feculent  vomitino-  has 
alternated  with  the  vomiting  of  mucous  and  bilious 
matters  only  it  must  be  assumed  that  the  act  con- 
cerned the  stomach  only  in  the  latter  case,  but 
extended  to  the  intestine  also  in  the  former. 

There  is  without  doubt  a  very  direct  association 
between  the  completeness  of  the  constipation  and  the 
severity  of  the  vomiting. 

In  a  few  exceptional  cases  of   a  chronic  nature 

I  find  that  vomiting  persisted  even  while  the  bowels 

acted  freely,  and  I  have  met  also  with  two  or  three 

instances  where  a  good  appetite  existed  in  patients 

*  Lancet,  vol.  i. ,  1878,  page  743. 


368  Intestinal  Obstruction.       [Chap.  xx. 

who  had  been  the  subjects  of  long-continued  obstruc- 
tion and  had  vomited  at  intervals  for  weeks. 

Constipation. — The  constipation  in  cases  of 
obstruction  of  the  bowels  depends,  of  course,  in  the 
main  upon  the  narrowing  or  occlusion  of  the  lumen  of 
the  intestine. 

It  may  depend  also  uj)on  paralysis  of  a  segment  of 
the  intestine  without  mechanical  obstruction  in  the 
intestine  itself,  as  has  been  explained  in  speaking  of 
chronic  constipation.  It  is  also  to  a  great  extent  due 
to  reflex  nerve-action.  Thus^  in  cases  of  acute  stran- 
gulation, the  constipation  is  often  absolute  from  the 
very  commencement,  although  the  obstruction  may  be 
in  the  small  intestine  and  much  fsecal  matter  be 
lodged  between  the  point  of  occlusion  and  the  anus. 
Then,  again,  constipation  is  very  usual  in  those  cases 
of  partial  obstruction  of  the  intestine  where  a 
segment  of  the  bowel  is  suddenly  and  severely 
nipped.  This  is  well  observed,  as  a  rule,  in  Littre's 
hernia,  where  only  a  part  of  the  circumference  of  the 
bowel  is  involved  in  the  strangulation.  Moreover, 
constipation  of  a  pronounced  type  is  observed  in  in- 
stances of  pseudo-strangulation. 

In  cases  of  acute  strangulation  it  is  not  infrequent 
for  the  part  of  the  bowel  below  the  obstruction  to  be 
emptied,  and  in  examples  where  some  catarrhal 
action  has  been  set  up  in  this  segment  of  the  bowel 
the  patient  may  present  the  evidences  of  a  copious 
diarrhoea. 

It  is  not  infrequent  in  acute  cases  of  obstruction 
for  a  stool  to  be  spontaneously  passed  just  before 
death.  This  may  be  derived  from  the  bowel  below 
the  occlusion,  and  may  be  due  to  certain  altered 
nerve  conditions  associated  with  impending  death,  or 
the  stool  may  be  derived  from  the  intestine  above 
the  point  of  stoppage  and  may  indicate  the  yielding 
of    the    obstruction    from    perforation    or   by    other 


Chap.  XX.]        The  Symptoms  :  Anuria.  369 

spontaneous  means.  Or  the  occlusion  may  have  been 
incomplete,  and  the  nerve  conditions  that  maintained 
the  constipation  may  have  become  modified  as  death 
approached. 

The  amount  of  urine  passed. — The  state- 
ment of  Dr.  Barlow,  that  the  higher  the  obstruction  is 
situated  in  the  intestine  the  less  is  the  amount  of 
urine  passed  by  the  patient,  has  been  fully  combated 
and  shown  to  be  incorrect.  The  anuria  or  oliguria  so 
often  observed  in  instances  of  intestinal  obstruction 
does  not  depend  upon  the  position  of  the  incarceration 
or  occlusion,  but  upon  its  nature. 

Anuria,  or  marked  oliguria,  is  met  with  in 
examples  of  acute  obstruction,  and,  provided  that  the 
general  severity  of  the  cases  is  the  same,  the  symptom 
is  as  marked  when  the  strangulation  involves  the 
sigmoid  flexure  as  it  is  when  it  involves  the  jeju- 
num. 

It  is  true  that  in  the  great  majority  of  cases  of 
acute  obstruction  the  part  involved  is  the  small  intes- 
tine, while  the  greater  number  of  the  chronic  cases 
have  a  locality  in  the  large  intestine,  yet  this  fact, 
although  it  lias  no  doubt  been  the  great  cause  of 
error,  can  obviously  not  influence  the  statement  just 
made. 

A  like  diminution  in  the  amount  of  urine  ex- 
creted is  met  with  in  cases  of  severe  injury  to  the 
abdomen,  in  wounds  involving  the  peritoneum,  and 
in  violent  attacks  of  hepatic  colic.  The  symptom, 
indeed,  in  these  cases,  as  well  as  in  the  earlier  stages 
of  acute  obstruction,  is  one  of  the  phenomena  of  shock, 
and  a  direct  result  of  the  diminished  pressure  of  the 
blood  in  the  aorta.  It  is  well  known,  moreover,  that 
the  amount  of  the  renal  excretion  may  be  afiected  by 
nerve  conditions  other  than  those  associated  with  col- 
lapse. 

Another  cause  of  anuria  in  acute  obstruction 
Y— 12 


370  Intestinal  Obstruction.        [Chap.  xx 

depends  upon  the  rapid  withdrawal  of  water  from  the 
body  l>y  the  violent  vomiting  and  l^y  the  not  infre- 
quently profuse  sweating.  The  symptom,  therefore, 
is  very  often  associated  with  another  symptom,  in- 
tense thirst. 

The  influence  of  opium  in  increasing  the  amount 
of  the  urinary  excretion,  when  once  it  has  been 
seriously  diminished,  is  often  very  marked.  The 
drug  acts  in  this  matter  by  modifying  the  effects  of 
shock,  by  stilling  certain  violent  nerve  movements,  by 
moderating  peristalsis  in  the  intestine,  and  by  render- 
ing the  vomiting  less  copious  and  severe.  "  The 
symptom  of  oliguria  has  a  significance  in  the  dif- 
ferential diagnosis  of  the  seat  of  the  obstruction  only 
in  cases  of  chronic  and  incomplete  occlusions  or  con- 
strictions of  the  intestine.  If  these  are  situated  high 
up,  the  amount  of  urine,  for  the  same  well-known 
reason  as  in  stenosis  of  the  pylorus,  is  constantly 
diminished,  and  this  is  not  the  case  when  the  occlu- 
sion is  in  the  lower  part  of  the  ileum  or  in  the  colon  " 
(Leichtenstern). 

The  subject  of  meteorism  will  be  discussed  when 
speaking  of  the  symptoms,  as  modified  by  the  position 
of  the  obstruction. 

Visible  intestinal  coils  in  movement  form 
a  symptom  often  noted  in  intestinal  occlusions,  and 
one  that  is  of  considerable  diagnostic  value. 

The  outlines  of  the  convolutions  and  their  peri- 
staltic movements  are  not  to  be  seen  through  the  ab- 
dominal walls  in  cases  of  acute  obstruction,  except  in 
very  rare  and  exceptional  instances.  In  examples  of 
chronic  obstruction,  however,  this  phenomenon  is 
quite  common.  It  becomes,  therefore,  of  much  value 
in  differential  diagnosis,  and  especially  in  heli)ing  the 
surgeon  to  distinguish  between  an  acute  attack  that 
has  supervened  upon  a  condition  of  chronic  obstruc- 
tion and  an  attack  that  has  been  acute  from  the  first. 


Chap,  xxi.i  The  Diagnosis.  371 

The  distinctness  with  which  the  intestinal  coils  are 
seen  when  in  movement  depends  mainly  upon  three 
circumstances  :  upon  the  degree  of  emaciation  of  the 
patient  and  the  consequent  thinness  of  the  abdominal 
parietes,  upon  the  hypertrophy  of  the  intestine  above 
the  obstruction,  and  upon  the  extent  of  distension  of 
the  hypertrophied  coils.  It  will  be  evident  that  the 
first  two  of  these  conditions  are  especially  prone  to  be 
associated  with  a  chronic  form  of  obstruction. 


CHAPTEE    XXI. 

THE    DIAGNOSIS    OP    THE    DIFFERENT    FORMS    OP 
INTESTINAL    OBSTRUCTION. 

The  difficulties  in  the  way  of  a  complete  diagnosis  of 
the  various  forms  of  intestinal  obstruction  are  both 
numerous  and  great. 

In  spite  of  the  comparative  frequency  of  the  con- 
dition, the  simple  recognition  of  its  existence,  quite 
apart  from  any  attempt  at  differentiating  its  various 
aspects,  is  often  a  matter  of  considerable  difficulty. 
It  is  doubtful  if  any  ailment  of  an  equally  common 
nature  has  been  the  subject  of  so  many  errors  in 
diagnosis.  Our  knowledge  of  the  pathology  of  the 
affection  is  by  no  means  imperfect,  and  yet  an  increase 
in  that  knowledge  has  not  been  attended  by  a  cor- 
responding increase  in  our  familiarity  with  the 
clinical  history  of  the  condition.  There  are  not  many 
maladies  that  present  so  slight  a  relationship  between 
pathological  data  and  clinical  data  as  does  the  general 
subject  of  intestinal  obstruction,  while  there  are  few 
in  which  it  is  more  important  that  that  relationship 
should  be  most  intimate. 


372  Intestinal  Obstruction.      [Chap.  xxi. 

Many  circumstances  conspire  to  make  differential 
diagnosis  in  cases  of  obstruction  a  matter  of  peculiar 
difficulty.  In  the  first  place,  the  different  forms  of 
intestinal  occlusion  depend  upon  a  number  of  very 
diverse  conditions.  The  bare  list  of  the  possible 
forms  of  obstruction  that  are  concerned  in  a  complete 
differential  diagnosis  is  almost  appalling.  Then,  again, 
certain  common  symptoms  are  capable  of  being  induced 
by  very  many  different  causes,  although  those  dif- 
ferent causes  may  act  probably  in  a  common  direction. 
How  many  and  diverse  are  the  morbid  conditions  that 
may  excite  simultaneously  the  gi^eat  symptoms  of  ob- 
struction, viz.  pain,  vomiting,  and  constipation ! 

It  must  be  remembered  also  how  many  anomalous 
cases  are  met  %\'ith  that  interfere  sadly  ^A\\\  any  general 
diagnostic  conclusions.  Thus,  without  making  any 
sj)ecial  enquiries,  I  have  found  among  the  recorded 
cases  of  intestinal  obstruction  that  I  have  collected 
no  less  than  twenty-two  examples  of  a  double  obstruc- 
tion existing  at  the  same  time  in  a  particular  case. 
In  some  of  these  instances  the  small  intestine  had 
been  occluded  in  two  places  while  in  other  examples 
an  obstruction  had  involved  both  the  large  and  the 
small  intestine  at  the  same  time.  One  can  understand 
also  how  any  definite  conclusions  as  to  stercoraceous 
vomiting  as  a  means  of  diagnosis  can  be  scattered  to 
the  winds  by  a  case  of  obstruction  associated  with 
a  fistulous  communication  between  the  colon  and  the 
upper  extremity  of  the  small  intestines. 

Many  of  the  errors  in  diagnosis  are  due  to  an 
incomplete  investigation.  Every  case  should  be  sub- 
jected to  a  systematic  method  of  examination.  The 
previous  history  should  be  carefully  studied,  as  well  as 
the  precise  mode  of  onset  of  tlie  disease  and  the  time 
and  mode  of  appearance  of  the  principal  symptoms. 
In  many  of  the  recorded  cases  no  information  is  fur- 
nished as  to  the  nature  of  the  pain,  as  to  its  situation. 


Chap.  XXI .  J  The  Dia  gnosis.  373 

the  duration  of  its  attacks,  their  manner  of  commence- 
ment -  and  of  cessation,  nor  of  tlie  length  of  the  in- 
terval between  given  attacks  of  pain,  nor  of  the 
condition  of  the  patient  during  those  intervals.  All 
evacuations  should  be  personally  inspected,  and  re- 
peated examinations  of  the  abdomen  made.  A  tumour 
not  evident  at  one  time  may  be  distinct  a  few  hours 
afterwards,  and  it  is  absurd  to  suppose  that  in  any 
given  case  all  information  derived  from  an  examina- 
tion of  the  belly  is  likely  to  be  obtained  during  one 
isolated  inspection. 

In  no  instance  should  the  surgeon  fail  to  examine 
all  the  hernial  orifices,  and  to  make  a  complete 
exj)loration  of  the  rectum. 

In  discussing  the  different  forms  of  intestinal 
obstruction  in  a  previous  chapter,  I  have  entered 
with  some  detail  into  the  nature  of  the  symjitoms 
that  are  associated  with  those  various  forms,  and  have 
also  pointed  out  many  of  the  features  essential  to  a 
differential  diagnosis. 

In  the  present  chapter  I  propose,  with  as  little 
repetition  as  j)ossiblc,  to  take  a  general  view  of  the 
whole  subject  with  reference  solely  to  the  matter  of 
diagnosis,  and  to  indicate  the  general  scheme  upon 
which  I  venture  to  think  that  all  attempts  at  diagnosis 
may  be  most  conveniently  conducted. 

For  purposes  of  diagnosis  all  cases  of  intestinal 
obstruction  may  be  divided  into  three  great  classes  or 
divisions. 

1.  Cases  oi^  acute  ousthuction. 

2.  Cases  oe  chhonic  obstruction. 

3.  Cases    where     symptoms     of     acute      oustkuction 

supervene   uron    those   indicative    of    a    chllonic 

OliSTRUCTION. 

This  division  is  of  course  quite  arbitrary,  and  it 
may  not  always  be  easy  to  place  a  given  case  defi- 
nitely in  one  of  these  three  divisions.     Many  cases  of 


374  Intestinal  Obstruction.      LChap.  xxi. 

intestinal  obstruction  adopt  such  a  course  as  to  enable 
a  division  to  be  established  for  subacute  forms.  Such 
examples,  however,  will  be  found  to  be  made  up  of 
forms  of  intestinal  obstruction  that  usually  adopt 
either  an  acute  or  a  chronic  course. 

1.    ACUTE    OBSTRUCTION. 

Let  it  be  supposed  that  a  patient  presents  the 
symptoms  of  acute  obstruction. 

The  sym^Dtoms  that  he  will  display  will  be  in 
general  terms  as  follows  :  He  has  been  seized  more  or 
less  suddenly  with  severe  abdominal  pain.  This  pain 
has  been  of  the  nature  of  colic.  It  may  be  constant 
and  liable  to  exacerbations,  or  be  more  or  less  dis- 
tinctly intermittent.  In  any  instance,  the  longer  the 
pain  lasts  the  more  does  it  tend  to  become  constant 
and  continuous.  The  patient  has  vomited.  The  vom- 
iting has  appeared  early,  is  copious  and  severe,  and 
may  soon  become  stercoraceous.  There  is  more  or  less 
absolute  constipation  with  some  distension  of  the 
abdomen.  There  is  great  constitutional  depression 
with  evidence  of  the  effects  of  shock.  Symptoms  such 
as  these  may  depend  upon  the  following  different  forms 
of  acute  obstruction : 

A.  Strangulation  by  bands  or  through  apertures. 

B.  Volvulus  of  the  colon. 

C.  Acute  intussusception. 

D.  Some  forms  of  obstruction  by  foreign  substances. 

A.  Straiigiilatioii  by  bauds  or  tlu'oiigli 
apertiu'es. — Under  this  heading  are  included  the 
following  : 

Strangulation  bj"  isolated  peritoneal  adhesions. 
„  by  omental  cords. 

„  by  Meckel's  diverticulum. 

„  by  normal  structures  abnormally  attached,  as 

by  an  adherent  appendix  or  Fallopian  tube. 
„  through  sUts  and  apertures  of  various  kinds. 


Chap.  XXL]  Acute  Obstruction.  375 

The  instances  of  obstruction  tliat  come  under  this 
heading  form  collectively  more  than  one-fourth  of  all 
the  varieties  of  intestinal  obstruction. 

Sex.  Age. — They  are  a  little  more  common  in 
males  than  in  females.  Are  most  usually  met  with  in 
young  adults,  and  are  very  rare  after  forty. 

Previous  history. — A  distinct  history  of  previous 
peritonitis  in  68  per  cent.  A  history  of  previous 
attacks  of  obstruction  like  to  the  present  in  12  per  cent. 

Mode  of  onset. — Sudden  in  over  70  per  cent. 

Fain  is  the  earliest  or  one  of  the  earliest  signs. 
Is  extremely  severe,  colicky,  continuous,  and  per- 
sistent. It  may  abate  a  little  as  the  case  advances. 
It  is  very  often  situated  about  the  umbilicus. 

Local  tenderness  is  usually  quite  absent  at  first,  but 
may  come  on  in  a  few  days. 

Vomiting  appears  early  ;  is  a  marked  symptom, 
being  constant,  copious,  and  severe.  In  60  per  cent, 
of  the  cases  it  becomes  stercoraccous,  on  an  average  on 
the  fifth  day.     It  affords  the  patient  no  relief. 

Consti2Jation  is  continuous  and  absolute  from  the 
first.  Encmata  may  evacuate  the  contents  of  the 
colon.     No  discharge  of  blood. 

Prostration  is  marked.  There  is  often  profound 
collapse,  intense  thirst,  diminished  urine,  etc. 

Tenesmus  is  absent. 

Abdominal  parietes  flaccid,  unless  peritonitis  has 
set  in. 

Meteorism  slight.  Appears  usually  about  the  third 
day.  Involves  first  the  epigastric  and  umbilical  re- 
gions in  most  cases. 

Tumours  or  localised  districts  of  dullness  caused 
by  the  distended  and  strangled  loops  are  extremely 
rare,  and  are  in  any  case  very  indefinite. 

Coils  of  intestine  arc  not  visible. 

The  average  duration  of  this  variety  is  about  five 
days. 


376  Intestinal  Obstruction.      [chap.  xxi. 

Under  this  form  of  intestinal  obstruction  may  also 
be  included  the  following  (all  very  rare)  : 

Strangulation  over  bands. 

Acute  kinking  of  the  small  intestine. 

Volvulus  of  the  small  intestine  (certain  cases). 

Certain  cases  of  tumour  outside  the  bowel  producing  an 

obstruction    of    the    small    intestine     by     sudden 

pressure. 

In  the  great  majority  of  instances  it  will  not  be 
possible  to  diagnose  these  difierent  varieties  from  one 
another,  but  all  the  facts  that  can  be  adduced  in  the 
support  of  a  differential  diagnosis  will  be  found  noted 
in  the  account  of  the  symptoms  that  attend  each 
of  these  varieties. 

B.  Volvulus  of  the-  colon. — This,  with  very 
few  exceptions,  which  will  not  be  here  considered, 
involves  the  sigmoid  flexure  only. 

Sex.  Age. — Volvulus  of  the  sigmoid  flexure  is 
more  common  in  males  than  in  females  in  the  propor- 
tion of  four  to  one.  It  is  very  rare  before  forty.  The 
patients'  ages  being  usually  between  forty  and  sixty. 

Previous  history. — In  nearly  every  case  there  is  a 
history  of  previous  constipation. 

Mode  of  onset. — Usually  sudden. 

Pain  appears  early.  Is  a  marked  symptom.  Is 
severe,  but  not  usually  so  severe  as  in  the  previous 
form.  Is  commonly  intermittent  at  first,  becoming 
subsequently  continuous  but  with  exacerbations.  Is 
very  often  complained  of  about  the  umbilicus,  and 
later  on  about  the  region  of  the  sigmoid  flexure. 

Local  tenderness  appears  early  over  the  region  of 
the  distended  coil  of  colon,  and  is  constant. 

Vomiting  appears  less  early  and  is  less  marked 
and  severe  than  in  the  previous  form  of  obstruction. 
It  may  be  absent.  It  is  often  scanty.  Is  feculent  in 
only  15  per  cent,  of  all  the  cases.  It  may  abate.  It 
often  affords  much  relief  to  the  patient. 


Chap.  XXL]  Acute  Obstruction:  377 

Constijmtion. — Early  and  absolute.  No  discharge 
of  blood. 

Prostration  not  so  marked  as  in  the  above  form  of 
strangulation.  There  may,  however,  be  marked  col- 
lapse, diminished  urine,  etc.  The  patient  often  suffers 
from  dysi^noea  and  a  sense  of  suffocation,  symptoms 
not  met  with  in  the  previous  class  of  case. 

Tenesmus  is  a  marked  feature  in  15  per  cent,  of 
the  examples. 

Abdominal  parietes  soon  become  rigid  owing  to  the 
early  and  almost  constant  appearance  of  at  least  local 
peritonitis. 

Meteorisin  appears  very  early,  increases  rapidly 
and  becomes  very  extreme.  The  thoracic  viscera  are 
often  displaced  by  the  distended  intestines. 

Tumours  of  a  definite  character  are  not  met  with ; 
nor  are  coils  of  intestine  visible. 

The  average  duration  is  six  days. 

Under  this  form  may  also  be  included  the  follow- 
ing (all  rare)  : 

Volvulus  of  other  parts  of  tiio  colon  (certain  cases). 
Cases  of  acute  bending  and  kinking  of  an  adherent  colon. 

The  symptoms  that  may  serve  to  distinguish  these 
different  forms  from  one  another  will  be  found  noted 
in  the  accounts  given  of  the  clinical  features  of  each 
separate  variety. 

C.  Acute  iiitusstiisceptioii. — Sex.  Age.  Some- 
what more  common  in  males.  Occurs  mostly  in  the 
young,  and  more  than  50  per  cent,  of  all  cases  are 
under  the  age  of  ten  years. 

Previous  history. — In  a  few  rare  instances  there 
is  an  account  of  previous  attacks  of  obstruction  due 
probably  to  intussusception. 

Mode  of  onset. — Sudden  in  75  per  cent,  of  the  cases. 

Pain. — One  of  the  first  symptoms.  Is  apt  to  be 
severe  at  first,  to  increase  up  to  a  certain  point,  and 


378  Intestinal  Obstruction.       LCiiap.  xxi. 

then  to  subside.  Is,  on  the  whole,  not  so  severe  as  in 
cases  of  strangulation  by  bands,  etc.  Is  at  first 
usually  distinctly  paroxysmal  or  continues  with  dis- 
tinct exacerbations.  It  may  be  localised  about  a 
tumour  to  be  felt  in  the  abdomen. 

Local  tetiderness  about  a  tumour  is  common. 

Vomiting  does  not  appear  so  early  as  in  the  two 
previous  varieties  of  obstruction,  and  is  usually  by  no 
means  so  severe.  In  three-fourths  of  the  cases  it  is 
among  the  earlier  symptoms,  while  in  the  remaining 
one-fourth  it  does  not  appear  until,  on  an  average,  the 
third  day.  In  8  per  cent,  of  acute  and  subacute 
cases  there  is  no  vomiting.  This  symptom  is  more- 
over liable  to  great  fluctuations,  and  may  be  absent 
for  a  while  and  then  reappear.  In  25  per  cent,  of  the 
cases  the  vomited  matters  become  feculent,  on  an 
average  upon  the  fourth  or  fifth  day. 

Constipation. — Absolute  constipation  is  extremely 
rare.  Constipation,  as  a  conspicuous  feature  in  the 
state  of  the  bowels,  is  noted  only  in  30  per  cent,  of 
the  cases.  Diarrhoea  is  more  usual,  and  in  80  per 
cent,  of  the  cases  there  is  an  evacuation  of  blood 
from  the  anus. 

Prostration. — In  the  more  acute  cases  there  is 
much  collapse,  especially  in  the  young,  but  on  the 
whole  the  amount  of  shock  is  less  than  in  cases  of 
strangulation  by  bands. 

Tenesmus  is  met  with  in  no  less  than  55  per  cent, 
of  the  cases,  and  is  often  an  early  symi)tom. 

The  abdominal  ^;arie^es  are  flaccid  unless  some 
peritonitis  has  set  in. 

Meteorism  is  quite  rare  except  in  cases  associated 
with  pronounced  constipation. 

Tumour. — A  definite  tumour  having  the  dis- 
tinctive character  described  in  chapter  x.  is  met 
with  in  50  per  cent,  of  the  cases.  A  tumour  is  fre- 
quently to  be  felt  in  the  rectum. 


Chap.  XXI.]  Acute  Obstruction.  379 

Coils  of  intestine  arc  not  visible. 

Tho  av(;rago  duration  of  ultra-acute  cases  is 
twenty-four  hours,  of  acute  cases  two  to  seven  clays, 
of  subacute  cases  from  seven  to  thirty  days. 

D.  Ob!!»lru<;lion  toy  fofcigii  bodies. — The 
principal  form  of  acute  obstruction  met  with  under 
this  h(!ading  depends  upon 

Cjvall  stones — It  must  be  distinctly  under- 
stood, however,  that  the  great  majority  of  gall  stones 
are  passed  along  the  intestine  without  producing  any 
symptoms,  and  that  many  in  their  passage  cause  but 
insignificant  symptoms.  In  other  instances  the  stone 
remains  in  the  intestine  quiescent  for  a  long  time, 
and  in  another  set  of  cases  evidences  of  chronic  ob- 
struction are  produced. 

In  a  few  examples  the  biliary  calculus  may  cause 
acute  obstruction.  In  such  cases  it  will  be  found 
lodged  in  the  duodenum,  jejunum,  or  more  usually  in 
the  lower  ileum. 

Sex.  Afje. — Gall  stones  are  much  more  common  in 
females  than  in  males.  The  average  age  is  fifty- 
seven  years. 

Previous  histo7"ij. — Gall  stones  may  have  been 
passed  previously.  In  many  cases,  however,  there  is 
no  liistory  of  an  antecedent  hepatic  colic.  There  may 
have  })een  evidences  of  local  peritonitis  about  the  gall 
bladder.  There  will  probably  have  been  previous 
attacks  of  acute  obstruction,  which  will  have  passed 
off  after  varying  short  periods. 

Nature  of  attack. — The  onset  is  usually  abrupt. 
There  is  severe  pain  of  a  continuous  character,  with 
exacerbations. 

The  pam  is  seldom  so  severe  as  in  strangulation 
by  bands. 

Vomiting  appears  early,  is  often  copious,  and  may 
in  time  become  stercoraceous. 

There  is  absolute  constipation. 


380  Intestinal  Obstruction.      [Chap.  xxi. 

The  average  duration  of  an  acute  fatal  attack  is 
seven  days. 

In  the  intervals  between  the  various  attacks  of 
acute  or  subacute  obstruction  the  patient  will  prob- 
ably have  suffered  from  indigestion,  irregular  action 
of  the  bowels,  and  the  like. 

Under  this  heading  may  also  be  included  : 

Some  cases  of  obstruction  by  foreign  bodies  that  have 

been  swallowed. 
Some  cases  of  obstruction  by  enteroHths. 

In  the  case  of  the  foreign  body  there  will  usually 
be  the  history  of  a  substance  swallowed. 

When  in  the  alimentary  canal  such  substances 
may  produce  the  same  effects  as  have  been  just  de- 
scribed as  occurring  in  cases  of  gall  stones. 

Enteroliths  lodge  mostly  in  the  caecum  or  colon. 
In  quite  exceptional  cases  they  may  cause  acute 
obstruction.  An  account  of  such  cases  is  given  with 
the  account  of  intestinal  calculi.  The  symptoms  are 
simply  those  of  acute  obstruction  of  the  nature  in- 
cident to  acute  occlusion  by  gall  stones.  In  some 
cases  fragments  of  the  concretion  have  been  passed. 
In  other  instances  the  mass  has  formed  a  tumour  that 
could  be  appreciated  through  the  parietes. 

2.    CHRONIC    OBSTRUCTION. 

The  causes  of  chronic  obstruction  of  the  bowels  are 
very  numerous  and  pathologically  very  varied.  For 
diagnostic  purposes  the  cases  may  be  divided  into  the 
four  following  classes  : 

A.  Stricture  of  the  small  intestine. 

B.  Stricture  of  the  large  intestine. 

C.  Faecal  accummulation. 

D.  Chronic  intussusception. 

A.   Stricture   of  tlie  small  iiitcstiiio. — Sex. 

Age.     In  the  matter  of  sex  there  is  nothing  to  notice. 
Non-cancerous  strictures    usually  occur   about  early 


Chap,  xxi.j         Chronic  Obstruction.  381 

middle  life ;  while  cancerous  strictures  are  very  rare 
before  forty. 

Previous  history. — In  non-cancerous  cases  there 
will  often  be  a  history  of  ulcer  of  the  intestine  or  of 
conditions  that  may  lead  to  destructive  changes  in  the 
gut,  e.g.  tuberculosis,  dysentery,  injury,  strangulated 
hernia,  typhlitis  (involving  the  ileum). 

Course. — The  onset  is  usually  gradual.  The  course 
of  the  malady  is  peculiarly  irregular.  Acute  attacks 
of  obstruction  are  apt  to  appear  from  time  to  time, 
and  the  case  is  often  fatal  through  an  acute  obstruc- 
tive attack. 

Pain. — The  pain  is  distinctly  intermittent,  long 
intervals  of  absolute  freedom  from  suffering  often  in- 
tervening between  the  attacks.  As  the  intervals 
between  the  paroxysms  shorten  the  attacks  become  of 
longer  duration.  These  intervals  may,  in  the  earlier 
periods  of  the  case,  amount  to  many  days  or  even 
weeks.  The  earlier  attacks  of  pain  are  slight,  and 
usually  ascribed  to  indigestion,  flatulence,  etc.  They 
are  very  usually  provoked  by  food,  and  especially  by 
indigestible  food.  As  time  advances,  the  attacks  be- 
come more  and  more  frequent,  and  more  and  more 
severe.  Wlien  complete  obstruction  sets  in,  as  in 
a  definite  attack  of  acute  obstruction,  the  pain  becomes 
continuous,  but  with  exacerbations. 

There  is,  in  uncomplicated  cases,  no  definite  local 
tenderness. 

Vomiting. — During  the  earlier  attacks  of  pain 
there  may  be  nausea.  In  the  more  severe  attacks  the 
patients  vomit.  The  vomiting  is  often  provoked  by 
food.  It  is  late  to  appear,  is  often  scanty,  and  is 
rarely  feculent,  except  towards  the  end  of  an  acute 
obstructive  attack.  In  the  interval  between  attacks 
of  pain  the  patient  either  feels  well,  or  complains  of 
indigestion  or  some  nausea,  and  trouble  with  the 
bowels. 


382  Intestinal  Obstruction.      [chap.  xxi. 

Constipation  is  a  leading  symptom  in  60  per  cent, 
of  the  cases.  In  40  per  cent,  there  is  constipation,  alter- 
nating with  diarrhoea.  During  the  more  abiding  acute 
attacks  the  constipation  becomes  absolute.  In  cases 
of  cancerous  stricture  blood  may,  as  a  rare  circum- 
stance, be  passed  by  the  anus. 

General  condition. — The  patient  becomes  emaci- 
ated, especially  in  the  carcinomatous  cases,  and  is 
worn  out  by  the  continued  pain  and  digestive  dis- 
turbances, Durmg  the  more  severe  acute  attacks 
there  may  be  prostration,  amounting  in  some  cases  to 
collapse. 

Teiwsmus  is  absent. 

The  abdominal  i^cirietes  remain  flaccid,  unless  peri- 
tonitis be  present. 

Meteorism  is  absent  except  during  the  attack  and 
during  absolute  constipation. 

Tumours. — In  non-malignant  cases  no  tumour  is 
to  be  felt.  In  the  cancerous  cases  a  tumour  is  to  be 
felt  in  30  per  cent,  of  the  examples. 

Coils  of  intestine. — The  movements  of  coils  of 
hypertrophied  intestine  are  visible  through  the 
parietes,  especially  during  attacks  of  colicky  pain. 
This  symptom  is  the  inore  distinct  the  more  marked 
the  emaciation. 

The  average  duration  of  the  cases  taken  together 
is  from  three  to  five  months. 

With  this  form  of  intestinal  obstruction  the 
following  diflerent  varieties  may  be  associated  for 
diagnostic  purposes : 

1.  Some  cases  of  bonding  of  adherent  small  intestine. 

2.  Some  cases  of  adhesions  binding-  a  portion  of  the  bowel 

into  a  fixed  loop. 

3.  Cases  of  compression  of  the  giit  by  adhesions. 

4.  Cases  of  matting  together  of  several  coils  of  intestine. 
6.  Cases  of  narrowing  of  the   gut  from  shrinking  of  an 

inflamed  mesentery. 
6.  Cases  of  stenosis  as  an  effect  of  traction. 


Chap.  XXI.]        Chronic  Obstruction.  383 

7.  Some  instances  of  volvulus. 

8.  Obstruction  by  neoplasms. 

9.  Some  cases  of  obstruction  by  gall   stones  and  foreig-n 

bodies. 
10.  Some  cases  of  compression  by  a  tumour  outside  the  gut. 

All  these  forms  of  intestinal  obstruction  may  pre- 
sent symptoms  that  more  or  less  closely  resemble  one 
another,  and  that  may  be  considered  to  find  their 
typical  representation  in  a  case  of  stricture  of  the 
lesser  bowel.  In  each  instance  it  will  be  noted  that 
there  is  some  permanent  but  partial  occlusion  of  the 
intestine. 

The  resemblance  between  these  various  forms  of 
intestinal  obstruction  is  very  commonly  so  close  that 
a  certain  difierential  diagnosis  is  impossible. 

Any  distinctive  features  (such  as  they  are)  that 
may  be  associated  with  any  of  the  above  forms  of 
obstruction  will  be  found  detailed  in  the  account 
given  of  each  of  these  varieties  in  the  previous  parts 
of  this  work. 

In  the  first  four  forms  there  will  probably  be  some 
history  of  a  local  peritonitis  that  gave  rise  to  the  adhe- 
sions producing  the  obstruction.  In  the  fifth  form 
there  may  be  the  same  feature  in  the  previous  history, 
or  some  evidence  of  mesenteric  gland  disease.  In  the 
ninth  form  there  will  be  the  history  associated  with 
gall  stones  and  foreign  bodies,  to  which  attention  has 
just  been  directed.  In  the  tenth  variety,  the  tumour, 
which  will  probably  have  origin  in  the  pelvis,  may,  in 
many  instances,  be  obvious  upon  examination. 

B.  Stricture  of  the  large  intestine. — In  these 
cases  the  symptoms  are  very  similar  to  those  asso- 
ciated with  stenosis  of  the  small  intestine.  In  the 
matter  of  sex  and  age  and  previous  history  there  are 
the  same  circumstances  to  be  noted  that  have  been 
alluded  to  in  the  previous  paragraph. 

The  course  of  the  malady  is  attended  by  a  similar 


384  Intestinal  Obstruction.      [Chap. xxi. 

irregularity,  and  by  the  same  kind  of  paroxysmal 
attack.  The  character  of  the  pain  is  the  same,  although 
upon  the  whole  it  is  less  severe.  Vomiting  appears 
with  less  frequency,  is  often  absent,  and  in  any 
instance  supervenes  at  a  later  period.  It  is  usually 
less  profuse  than  is  the  case  in  stenosis  of  the  lesser 
bowel.  It  never  becomes  stercoraceous  except  after 
many  days  of  absolute  constipation.  Unlike  what  is 
the  case  in  stricture  of  the  small  intestine,  the  symp- 
toms, when  the  colon  is  involved,  are  usually  but  little 
affected  by  food. 

The  hoimls  are  usually  in  a  condition  of  constiiDa- 
tion,  and  the  size  and  outline  of  the  motions  is 
frequently  altered. 

Tenesmus  is  very  commonly  present.  Aperients 
often  give  relief  in  cases  of  stricture  of  the  small 
intestine,  but  are  apt  to  aggravate  the  symptoms 
when  a  like  narrowing  involves  the  colon.  In  cases 
of  cancerous  stricture,  diarrhcea  with  constipation  is 
common,  and  in  15  per  cent,  of  the  examples  there 
was  a  hloocly  discharge  from  the  anus.  Tenesmus  is 
especially  marked  in  such  cases  as  are  associated 
with  diarrhoea. 

Meteorism  is  often  very  pronounced,  and  the  coils 
of  intesti7ie  are  visible  through  the  wasted  parietes. 
In  cases  of  simple  stricture  no  tumour  is  to  be  felt, 
but  in  the  cases  of  malignant  disease  a  tumour  is  to 
be  detected  through  the  abdominal  walls  in  no  less 
than  40  per  cent,  of  the  examples. 

With  this  form  the  following  different  varieties 
may  be  associated  for  diagnostic  pur})oses  : 

1.  Some  cases  of  bending  of  adherent  colon. 

2.  Compression  of  the  gut  by  adhesions. 

3.  Some  cases  of  volvuhis  of  the  caecum. 

4.  Obstruction  by  neoplasms. 

5.  Compression  by  a  tumour  outside  tlie  gut. 

6.  Some  cases  of  enterolith. 


Chap.  XXL]         Chronic  Obstruction.  385 

Tlie  symptoms  associated  with  these  clifTerent 
varieties  will  be  found  detailed  in  the  accounts  given 
of  them  in  previous  chapters.  These  symptoms  gene- 
rally accord  with  those  of  stricture  of  the  colon,  and 
the  features  in  the  differential  diagnosis  are  not 
well  marked.  Some  diagnostic  value  attaches  to  the 
previous  history  of  the  patient,  as  has  been  already 
pointed  out  in  connection  with  the  different  forms 
of  obstruction  that  resemble  stricture  of  the  lesser 
bowel. 

C.  Faecal  accuinulatioiis.— This  form  of  ob- 
struction is  mostly  met  with  in  adults,  and  more 
frequently  in  females  than  in  males.  It  is  especially 
common  among  lunatics,  and  the  subjects  of  hysteria 
and  hypochondriasis. 

The  symptoms  consist  mainly  in  a  gradually  in- 
creasing constipation,  which  more  and  more  resists 
the  action  of  aperient  medicines.  The  patient's 
appetit(3  declines,  his  tongue  becomes  foul,  he  is  liable 
to  eructations  and  nausea,  and  often  feels  languid  and 
depressed. 

As  the  case  advances,  the  abdomen  becomes  more 
and  more  distended.  Some  of  the  coils  of  intestine 
are  visible  through  the  parietes.  The  ^accumulated 
fajcal  masses  may  press  upon  the  lumbar  or  sacral 
nerves,  or  upon  the  iliac  or  pelvic  veins,  and  so  pro- 
duce certain  symptoms  as  a  direct  result  of  that 
pressure. 

As  the  obstruction  becomes  more  complete,  the 
abdomen  may  become  painful.  This  pain  will  assume, 
at  first  at  least,  a  paroxysmal  character,  becoming, 
later  on,  continuous,  but  with  exacerbations.  Vomit- 
ing may  occur.  It  appears  late,  comes  on  very 
gradually,  is  scanty,  and  rarely  becomes  feculent 
unless  the  obstruction  have  remained  absolute  for  a 
considerable  period. 

The  patient  may  be  liable  from  time  to  time  to 
z— 12 


386  Intestinal  Obstruction.        [Chap.  xxi. 

obstructive  attacks  associated  with  pain  and  vomiting, 
which  are  usually  soon  relieved  by  enemata. 

The  diagnosis  is  assisted  by  the  history  of  the 
case,  by  the  account  given  by  the  patient  of  long-con- 
tinued and  increasing  constipation,  and  possibly  also 
of  certain  previous  obstructive  attacks  that  have  been 
relieved  by  eneinata. 

The  most  important  feature,  however,  in  the 
diagnosis  is  the  faecal  tumour.  This  mass  is  usually 
most  distinctly  marked  when  it  occupies  the  caecum. 
Its  characters  are  ])ronounced,  and  have  been  fully 
described  in  the  account  of  obstruction  by  fsecal  masses 
given  in  chapter  xix. 

At  almost  any  time  the  patient  may  develop  the 
symptoms  of  acute  obstruction.  This  depends  upon 
an  absolute  blocking  of  the  intestine  as  a  result  of 
paralysis  of  a  portion  of  it.  An  account  of  this  form 
of  obstruction  is  given  under  the  title  of  ileus 
paralyticus. 

D.  Chronic  iiitussiisceptioii.— No  form  of  in- 
testinal obstruction  offers  so  many  difficulties  in  the 
way  of  its  recognition  as  does  chronic  intussusception, 
and  no  form  has  been  the  subject  of  more  errors  in 
diagnosis. 

The  term  is  applied  to  cases  having  a  duration  of 
not  less  than  one  month.  The  cases  may  last  for 
many  months.  The  course  of  the  malady  is  extremely 
irregular.  There  may  be  at  one  time  constipation  and 
at  another  diarrhoea,  at  one  time  pain  and  at  another 
none.  There  is,  moreover,  no  method  in  this  irre- 
gularity. 

Sex.  Age. — These  cases  are  met  with  more  fre- 
quently in  males  than  in  females,  and  are  most 
common  during  the  period  of  active  adult  life. 

The  mode  of  onset  is  sudden  or  abrupt  in  about  35 
per  cent,  of  the  cases,  the  symptoms  subsequently 
becoming  more  chronic.     This  feature  when  present  is 


ciiap.  XXI.]         Chronic  Obstruction.  387 

of  much  value  when  diagnosing  this  from  other  forms 
of  cljronic  obstruction. 

Fain  is  distinctly  intermittent,  and  for  long  in- 
tervals may  he  entirely  absent.  These  intervals 
become  shorter  as  the  disease  advances,  while  the 
duration  of  the  attacks  of  pain  is  increased.  The  pain 
is  seldom  severe,  and  is  often,  indeed,  insignificant. 

Vomiting  is  a  marked  feature  in  only  a  little  over 
50  per  cent,  of  the  cases.  In  6  per  cent,  it  is  entirely 
absent  throughout  the  progress  of  the  disease.  It  is 
very  irregular  in  its  appearance,  and  commonly  coin- 
cides with  the  attacks  of  paroxysmal  pain.  It  is 
seldom  copious  or  distressing,  and  is  feculent  only 
in  about  7  per  cent,  of  the  cases.  It  may  be  induced 
in  the  earlier  stages,  and  made  worse  in  the  later 
stages,  by  food. 

Constipation. — The  state  of  the  bowels  varies 
greatly.  They  may  be  normal.  As  a  rule  they  are 
irregular,  sometimes  with  a  tendency  to  constipation, 
but  more  frequently  with  a  tendency  to  diarrhcea.  In 
no  less  than  50  per  cent,  of  the  cases  a  bloody  dis- 
charge from  the  anus  is  to  be  expected. 

In  about  13  per  cent,  of  the  examples  of  this 
afiection  there  is  marked  tenesmus. 

General  condition. — The  patient  wastes,  becomes 
cachectic  and  anaemic,  and  not  infrequently  dies  of 
exhaustion  and  marasmus. 

The  abdominal  walls  are  quite  flaccid. 

Meteorism  is  absent  except  during  attacks  of  tem- 
porary obstruction  or  during  pronounced  constipation. 
In  any  case  it  will  be  quite  slight. 

Coils  of  intestine  are  often  very  clearly  seen  in 
movement  through  the  wasted  parietes. 

Tumours.  — An  abdominal  tumour  of  a  more  or  less 
distinctive  character  is  to  be  felt  in  about  one  half  of 
the  cases.  In  32  per  cent,  of  the  examples  the  invagi- 
nated  mass  reached  the  rectum. 


388  Intestinal  Obstruction.      [Chap.  xxi. 

3.  CASES  WHERE  AN  ATTACK  OF  ACUTE  OBSTRUCTION 
SUPERVENES  UPON  SYMPTOMS  INDICATING  A  CHRONIC 
OBSTRUCTION. 

There  is  no  one  of  the  many  forms  of  chronic  ob- 
struction alluded  to  in  the  preceding  paragi-aphs  in 
which  there  may  not  abruptly  develop  all  the  evidences 
of  acute  occlusion.  So  important  is  it  to  recognise 
these  cases  that  I  have  ventured  to  make  of  them  a 
special  class. 

If  the  acute  obstructive  attack  develop  wliile  the 
case  is  under  the  observation  of  the  surgeon  there  can 
of  course  be  no  difficulty  in  the  diagnosis.  If,  however, 
the  patient  is  seen  for  the  first  time  during  the  height 
of  one  of  such  attacks,  then  the  symptoms  may  be  very 
readily  considered  to  depend  upon  one  or  other  of  the 
pathological  conditions  that  lead  to  acute  strangula- 
tion. Thus  the  abdomen  has  been  opened  under  the 
impression  that  a  coil  of  intestme  was  strangulated  by 
a  band,  and  the  primary  cause  of  the  occlusion  found 
to  be  a  stricture  of  the  bowel.  It  might  be  said  at 
once  that  there  is  no  one  special  form  of  intestinal 
obstruction  that  can  be  placed  in  this  class  and  in  no 
otlier.  There  is  no  form  of  chronic  obstruction  of  the 
bowels  that  invariably  leads  to  an  acute  attack. 

The  most  common  varieties  of  chronic  obstruction 
are  those  that  depend  upon  fiecal  accumulation  and 
upon  stricture  of  the  colon.  In  the  former,  the  con- 
dition known  as  ileus  paralyticus  may  at  any  moment 
develop,  and  the  surgeon  be  confronted  with  a  form  of 
intestinal  obstruction  that  often  presents  very  pro- 
nounced and  violent  features.  In  connection  with 
strictures,  also,  the  case  may  proceed  quietly  for 
months,  the  stenosed  part  becoming  narrower  and 
narrower,  and  the  symptoms  more  and  more  clearly 
defined.  Suddenly  the  patient  develops  an  acute 
attack   of  ileus;    and   if  death   results  the  gut  will 


Chap.  XXL]         Chronic  Obstruction.  389 

be  found  to  have  become  suddenly  occluded  at  the 
narrowest  part.  This  occlusion  may  be  due  to  kinking 
or  to  acute  bending  of  the  bowel,  or  to  blocking  of 
the  stricture  by  some  foreign  substance,  or  by  a  fsecal 
mass  or  a  mass  of  undigested  food.  If  the  stricture 
involve  the  upper  parts  of  the  rectum  then  the  dis- 
tended sigmoid  flexure  above  the  stenosis  may  be  found 
to  have  become  twisted  upon  itself,  and  to  have 
brought  about  the  condition  of  volvulus. 

In  the  less  common  forms  also  of  chronic  obstruction 
the  same  conditions  may  be  met  with.  Thus,  chronic 
intussusception  very  often  ends  in  an  acute  attack 
which  may  prove  rapidly  fatal.  Coils  of  intestine 
matted  together  by  adhesions  may  become  suddenly 
occluded  by  bending  or  kinking,  at  one  or  more  points, 
and  so  lead  to  acute  manifestations.  A  case  of 
chronic  volvulus,  or  of  volvulus  associated  with  slight 
symptoms,  may,  as  a  result  of  distension  or  of  para- 
lysis, become  at  any  moment  an  example  of  acute 
volvulus  with  the  appropriate  symptoms.  Any  portion 
of  the  bowel  partially  occluded  by  compressing  ad- 
hesions or  by  a  tumour  outside  its  walls,  or  by  a 
neoplasm  or  a  foreign  substance  within  its  lumen,  may 
become  at  a  moment  completely  obstructed  by  any  of 
the  causes  just  referred  to  when  speaking  of  the  sudden 
occlusion  of  strictures. 

The  patient  may  have  many  of  such  attacks,  and 
these  very  often  exhibit  an  increasing  degree  of 
severity. 

With  regard  to  the  diagnosis  between  these  quasi- 
acute  attacks  and  cases  of  acute  strangulation  of  the 
bowel,  such  as  may  be  due,  for  example,  to  bands,  the 
most  important  factor  is  the  patient's  past  history. 
There  will  be  usually  a  history  of  such  symptoms  as 
have  been  described  as  incident  to  chronic  obstructions, 
and  there  will  probably  have  been  previous  attacks  of 
like  character  but  of  less  pronounced  severity. 


39°  Intestinal  Obstruction.      [Chap.  xxi. 

These  attacks  also  are  distinctly  less  abrupt  and 
less  violent  than  are  the  examples  of  acute  strangula- 
tion. The  pain  is  usually  by  no  means  so  severe,  nor 
is  the  condition  of  prostration  so  marked.  To  one 
sign,  however,  in  the  differential  diagnosis  too  much 
importance  can  scarcely  be  attached.  It  is  this.  In 
the  acute  attack  supervening  in  a  chronic  case,  the 
coils  of  intestine  may  be  visible  through  the  thinned 
parietes,  a  symptom  that  will  be  absent  in  cases  of 
primary  acute  obstruction.  In  the  former  variety  of 
case  the  symptom  may  be  lost  sight  of  if  the  meteor- 
ism  become  extreme,  or  if  peritonitis  develop,  and  it 
may  be  rendered  much  less  distinct  if  the  peristaltic 
movements  have  been  moderated  by  the  use  of  opium. 

There  are  unfortunately  a  few  rare  cases  in  which 
the  presence  of  a  partial  obstruction  of  the  intestine  is 
revealed  for  the  first  time  by  an  acute  attack.  That 
is  to  say,  a  stricture  exists  in  the  intestine  (most  pro- 
bably in  the  small  intestine),  but  it  has  not  yet  so 
narrowed  the  lumen  of  the  tube  as  to  cause  symptoms. 
On  a  sudden,  however,  the  stenosed  part  becomes 
blocked  by  a  mass  of  undigested  food,  or  the  bowel 
becomes  occluded  by  kinking  at  the  seat  of  stricture, 
and  symptoms  are  thereby  produced  that  assume  at 
once  an  acute  character.  An  acute  attack  occurring 
under  these  circumstances  may  be  fatal,  and  there  are 
cases  recorded  where  a  stricture  of  the  small  intestine 
has  revealed  itself  by  one  attack  of  rapidly  developing 
obstruction  which  has  ended  in  death.  The  diagnosis 
of  such  a  case  would  in  the  present  state  of  oui* 
knowledge  be  an  impossibility. 


391 


CHAPTER  XXII. 

THE    SYMPTOMS    AS    MODIFIED    BY    THE    POSITION    OF  THE 
OBSTRUCTION. 

The  questions  to  be  considered  nnder  tins  heading 
practically  resolve  themselves  into  an  examination  of 
the  clinical  differences  between  obstruction  situated  in 
the  small  and  in  the  large  intestines. 

The  differences  between  cases  of  stoppage  situated 
in  these  two  segments  of  the  bowel  have  frequently 
been  described  in  great  detail,  but  I  think  that  the 
supposed  distinctions  laid  down  are  often  entirely 
fallacious. 

It  is  true  that  the  larger  number  of  the  cases 
of  obstruction  of  the  colon  tend  to  assume  a  chronic 
course,  while  the  larger  number  of  cases  situated  in 
the  small  intestine  tend  to  take  on  an  acute  character. 
Thus,  a  very  slight  observation  of  a  series  of  in- 
stances of  intestinal  occlusion  may  appear  to  demon- 
strate conspicuous  differences  between  an  obstruction 
in  the  large  intestine  and  one  in  the  small. 

When,  however,  cases  of  like  degree  are  com- 
pared, when  cases  of  chronic  obstruction  in  the  colon 
are  compared  with  chronic  cases  involving  the  lesser 
bowel,  and  when  acute  obstructions  in  the  one  seg- 
ment are  compared  with  like  obstructions  in  the  other, 
it  will  be  fomid  that  the  great  bulk  of  the  fancied  dis- 
tinctions entirely  disappears.  Thus  it  would  seem  to 
be  commonly  supposed  that  obstructions  of  the  colon, 
when  compared  with  those  of  the  small  intestine,  are 
apt  to  assume  a  tardy  course,  to  be  associated  with 
comparatively  little  pain,  and  with  a  slighter  degree 
of  constitutional  disturbance,  and  to  be  attended  by 


392  Intestinal  Obstruction.     [Chap.  xxii. 

vomiting  that  appears  late  and  is  much  less  profuse 
and  distressing. 

This  will  be  true  as  regards  the  more  common 
forms  of  obstruction  of  the  colon,  but  it  does  not  apply 
to  the  acute  forms.  A  case  of  volvulus  of  the  sigmoid 
flexure  may  present  symptoms  as  violent  and  as 
rapidly  developed  as  any  met  with  in  cases  of  acute 
strangulation  of  the  small  intestine.  Indeed,  the 
more  extensive  the  comparison  between  obstructions 
in  the  large  and  obstructions  in  the  small  intestine, 
the  more  distinctly  does  it  become  evident  that  the 
clinical  distinctions  are  not  emphatic,  and  that  they 
depend  more  upon  the  nature  of  the  occlusion  than 
upon  its  situation. 

Still,  however,  after  all  these  reservations  have 
been  made,  it  will  be  found  that  there  are  a  few 
features  that  may  be  made  a  basis  for  comparison  in 
cases  of  a  fairly  equal  degree  of  severity,  although  it 
is  desirable  that  their  individual  ^'alue  should  not  be 
over-estimated  in  diagnosis. 

In  comparing  obstructions  of  the  colon  with  those 
of  the  lesser  bowel,  it  is  desirable,  in  the  first  place,  to 
note  the  physiological  differences  between  these  two 
segments  of  the  alimentary  canal.  The  small  intes- 
tine is  active  and  very  vigorously  concerned  in  the 
business  of  the  organism,  it  takes  a  large  and  im- 
portant share  in  the  process  of  digestion,  its  walls  are 
muscular,  its  blood-vessels  are  numerous,  and  its 
nerves,  ha^^ng  origin  from  the  superior  mesenteric 
plexus,  are  brought  into  very  direct  connection  with 
the  creat  nerve-centres  of  the  abdomen.  On  the  other 
hand,  the  function  of  the  large  intestine  is  to  a  great 
extent  passive.  It  serves  as  a  receptacle  for  the 
contents  of  the  bowel,  so  that  long  intervals  may 
elapse  between  the  evacuation  of  those  contents.  In 
one  sense  the  ileo-c?ecal  valve  may  be  regarded  as  a 
kind  of  internal  anus.     An  accumulation  of  matter  in 


Chap.  XXII.]    The  Diagnosis  of  the  Seat.  393 

the  small  intestine  soon  causes  distress,  but  such  accu- 
mulations in  the  colon  are,  within  certain  limits, 
normal.  The  large  intestine  is  not  so  muscular  as  the 
small,  nor  so  freely  supplied  with  blood.  Its  nerves 
also  are  in  great  part  derived  from  the  inferior  mesen- 
teric plexus,  and  have  thus  a  comparatively  indirect 
connection  with  the  principal  abdominal  nerve 
centres.  Such  parts  of  the  colon  as  are  supplied  by 
the  superior  mesenteric  plexus  are  supplied  by  the 
filaments  of  that  plexus  that  are  most  remote  from  the 
main  source  of  origin  of  the  nerves.  It  is  said  also 
that  the  intraparietal  nerve  plexuses  of  the  intestine 
are  more  elaborately  developed  in  the  small  than  in 
the  large  intestine.  Lastly,  the  colon  has  a  less  ex- 
tensive connection  with  the  peritoneum,  and  has 
therefore  a  correspondingly  less  elaborate  nerve  re- 
lation. 

From  all  this  it  would  appear  that  life  is  more 
active  in  the  small  gut  than  in  the  large ;  processes  in 
the  former  are  more  vigorous,  and  morbid  changes  are 
likely  to  show  an  equivalent  degree  of  activity  in  the 
lesser  bowel ;  moreover,  one  may  expect  to  find  all 
reflex  nerve  movements  carried  on  with  a  much 
greater  alacrity  than  in  the  colon. 

This  last  matter,  however,  is  somewhat  modified 
by  the  peritoneum.  There  is  no  evidence  to  show 
that  there  is  any  anatomical  or  physiological  differ- 
ence between  the  serous  membrane  as  it  covers  the 
small  intestine  and  as  it  covers  the  colon.  When,  in 
two  cases  of  obstruction  (one  in  the  small  gut  and 
one  in  the  large),  an  equal  amount  of  peritoneum  is 
damaged  to  an  equal  extent,  it  may  be  anticipated 
that  the  nerve  disturbances  arising  from  that  lesion 
will  not  be  very  dissimilar.  And  in  connection  with 
this  matter  it  is  noticeable  that  the  form  of  obstruc- 
tion of  the  colon  that  most  closely  resembles  acute 
strangulation  of  the  small  intestine  is  volvulus  of  the 


394  Intestinal  Obstruction,     tchip.  xxii. 

sigmoid  flexure,  where,  as  is  well  known,  a  very  ex- 
tensive surface  of  peritoneum  is  involved 

In  these  cases  it  would  appear  that  the  greater 
surface  of  serous  membrane  involved  in  the  volvidus, 
as  compared  with  the  amount  usually  implicated  in 
small  gut  strangulations,  has  been  able  to  overbalance 
the  anatomical  differences  between  the  large  and  small 
intestine  as  regards  their  ability  to  form  the  basis  of 
symptoms. 

After  these  preliminary  remarks,  a  comparison 
may  now  be  made  between  the  clinical  features  of  ob- 
structions in  the  large  and  small  intestines. 

Pain. — In  the  small  intestine  the  pain  usually 
appears  earlier,  is  more  pronounced,  more  abiding, 
and  more  severe. 

Vomiting. — In  the  small  intestine,  as  compared 
with  the  large,  this  symptom  appears  earlier,  is  more 
distressing,  and  is  more  persistent.  In  the  obstruc- 
tions of  the  lesser  bowel  the  vomited  matters  are  often 
copious,  are  apt  to  be  influenced  by  food,  and  more 
readily  become  feculent  than  is  the  case  when  the 
stoppage  is  in  the  colon.  Vomiting  due  to  trouble  in 
the  large  intestine  may  become  irregular,  may  cease 
for  awhile,  and  may  be  comparatively  slight. 

Constitutional  disturbance  is,  other  things  being 
equal,  certamly  more  marked  in  small  gut  obstructions 
than  in  those  of  the  colon.  There  is  a  gi'eater  ten- 
dency to  severe  collapse,  and  consequently  a  more 
frequent  appearance  of  the  various  remote  phenomena 
connected  with  shock. 

Meteorism. — When  the  lower  part  of  the  small 
intestine  is  obstructed,  the  meteorism  first  shows  itself, 
and  remains  for  awhile  most  marked,  in  the  hypo- 
gastric, epigastric,  and  umbilical  regions.  In  typical 
cases  the  abdomen  presents  the  appearance  of  a  six 
months'  pregnancy,  and  the  flanks  and  iliac  fossfe  are 
depressed.     This  symptom,   however,  is    of  no  great 


Chap.  XXII.]    The  Diagnosis  OF  THE  Seat.  395 

value,  for  the  appearance  may  be  almost  exactly 
imitated  by  a  distension  of  the  sigmoid  flexure,  when 
that  part  of  the  gut  forms  a  large  coil,  which  projects 
towards  the  middle  line  of  the  abdomen. 

When  the  lower  part  of  the  colon  is  involved  the 
meteorism  will  attain  a  much  greater  degree  than  it 
does  in  small  gut  obstructions.  Indeed,  upon  the 
whole,  it  may  be  said  that  meteorism  is  less  in  the 
latter  cases  than  in  the  former. 

Distension  of  the  colon,  especially  when  with  solid 
matters,  may  map  out  very  precisely  the  anatomical 
outline  of  the  bowel  and  leave  the  central  parts  of  the 
abdomen  comparatively  undistended.  In  any  case, 
however,  the  meteorism  tends  to  become  general,  and 
any  appearances  that  may  be  regarded  as  typical  are 
soon  lost.  In  diagnosing  acute  volvulus  of  the  sigmoid 
flexure  from  some  acute  strangulation  of  the  small  in- 
testine, great  importance  attaches  to  the  rapid  deve- 
lopment of  a  high  grade  of  meteorism  in  the  former 
affection. 

Apart  from  this  point  in  diagnosis,  I  do  not  think 
that  anything  like  the  importance  attaches  to  meteor- 
ism as  a  means  of  diagnosis  that  has  been  ascribed  to 
it.  In  certainly  the  great  majority  of  cases  the  rules 
given  in  connection  with  this  matter  in  many  text- 
books and  monographs  are  not  reliable. 

In  obstruction  situated  in  the  up2:)eT  ixirt  of  the  je- 
junum and  in  the  duodenum  we  find  that  the  symp- 
toms are  more  distinctly  influenced  by  the  seat  of  the 
stoppage.  In  acute  cases  collapse  appears  early  and 
assumes  a  grave  degree,  and  the  progi-ess  of  the  case 
is  usually  rapid  and  deliberate.  In  any  case  vomiting- 
is  among  the  earliest  symptoms.  The  matters  vomited 
are  usually  very  copious,  are  always  stained  with  bile, 
and  never  become  feculent.  The  vomiting  then  gives 
temporary  relief,  and  is,  with  the  other  symptoms, 
often  distinctly  aggravated  by  taking  food.       There 


396  Intestinal  Obstruction.     [Chap.  xxii. 

may  be  no  meteorism  and  the  abdomen  may  indeed  be 
even  retracted.  When  meteorism  is  present  it  will 
be  slight  in  degi'ee,  limited  to  the  epigastrium,  and 
apt  to  be  greatly  diminished  by  a  copious  vomiting. 
In  cases  of  chronic  obstruction  there  will  be  evidences 
of  ectasia  of  the  stomach. 

It  now  remains  to  consider  certain  means  of  inves- 
tigation that  have  been  adopted  with  the  especial 
object  of  diagnosing  obstructions  of  the  large  and  of 
the  small  intestine  from  one  another.  These  means 
are :  1 ,  enemata ;  2,  the  passage  of  the  long  tube ; 
3,  auscultation  of  the  colon. 

1.  Eiicmata. — A  great  deal  has  been  written  by 
various  authors  npon  the  value  of  enemata  as  a  means 
of  diagnosing  the  seat  Of  the  obstruction.  The  feature 
in  this  method  consists  in  a  comparative  estimation  of 
the  amount  of  water  that  can  be  held  by  certain 
segments  of  the  bowel.  Thus  elaborate  statements 
have  been  made  to  the  effect  that  if  a  certain  amount 
of  water  can  be  readily  injected  then  the  obstruction 
must  be  in  the  sigmoid  flexure,  if  a  certain  additional 
quantity  can  be  introduced  then  the  stoppage  must  be 
in  the  descending  colon,  and  finally  if  a  certain  number 
of  ounces  or  pints  can  be  received  then  the  whole  of 
the  large  intestine  must  be  occupied  and  the  occlusion 
must  be  situated  in  the  small  bowel.  Dr.  Brinton,  for 
example,  has  given  very  detailed  instructions  upon 
this  head.  The  statements  are  usually  based  upon  ex- 
periments made  upon  the  cadaver  with  reference  to 
the  actual  amount  of  fluid  that  various  segments  of 
the  colon  can  accommodate. 

For  diagnostic  purposes  this  method  is,  I  venture  to 
think,  absolutely  useless.  In  the  first  place,  observa- 
tions made  upon  the  cadaver,  where  the  parts  are 
relaxed  and  where  muscular  action  has  ceased,  are  not 
likely  to  be  identical  with  those  made  upon  the  living 
subject.     The   method,  moreover,  does   not  take  into 


Chap.  xxiT.]   The  Diagnosis  of  the  Seat.  397 

consideration  the  condition  of  the  bowel  below  the 
obstruction.  This  part  of  the  tube  may  be  dilated  or 
contracted,  may  respond  vigorously  to  certain  forms  of 
irritation  or  remain  absolutely  inert.  Then,  again,  as 
Dr.  Hilton  Fagge  has  pointed  out,  there  are  certain 
strictures,  especially  those  associated  with  some  bend- 
ing of  the  gut  or  with  a  valvular  arrangement  of  the 
mucous  membrane  above  the  stenosed  part,  through 
which  water  may  be  injected  from  below  while  fluids 
above  the  stricture  are  unable  to  find  a  way  to  escape. 
I  have  myself  in  many  cases  had  an  opportunity  of 
verifying  the  fallacies  in  this  reputed  method  of 
diagnosis,  and  many  published  cases  serve  also  to 
illustrate  these  errors.  As  an  example  I  may  cite  one 
instance  of  stricture  of  the  sigmoid  flexure  where  over 
three  pints  of  water  were  introduced  by  an  enema 
and  were  retained  for  twenty-five  minutes.  This 
large  quantity  of  fluid  must  have  been  accommodated 
in  the  rectum,  since  the  autopsy  revealed  that  none 
had  passed  beyond  the  stricture."^ 

2.  The  passag:c  of  tlie  loiig^  tube. — In  this 
method  a  flexible  tube  or  sound  is  passed  into  the 
rectum,  and  an  attempt  is  made  to  diagnose  the  seat 
of  the  obstruction  by  noting  to  what  distance  the  tube 
can  be  introduced.  This  procedure  applies  mainly  to 
stenosis  of  the  lower  part  of  the  colon.  As  a  means 
of  diagnosis  it  is,  I  believe,  entirely  valueless.  In 
some  cases  the  sound  has  lodged  early  in  its  career 
against  a  fold  of  mucous  membrane,  and  the  diagnosis 
of  an  obstruction  low  down  in  the  bowel  has  been  in 
consequence  made.  In  other  instances  in  stricture  of 
the  termination  of  the  sigmoid  flexure  the  tube  has 
reached  the  upper  extremity  of  the  rectum,  and  has 
then  turned  upon  itself,  or  become  coiled  up  in  the 
rectal  ampulla,  until  so  much  has  been  introduced  that 
the  whole  of  the  colon  downwards  from  the  splenic 
*  Path.  Soc.  Trans.,  vol.  vii.,  page  207. 


398  Intestinal  Obstruction.     [Chap.  xxii. 

flexure  has  been  diagnosed  to  be  free  from  obstruc- 
tion. I  have  good  reasons  for  doubting  if  these  rectal 
sounds  ever  go  beyond  the  sigmoid  flexure.  This  im- 
pression is  fully  confirmed  by  experiments  made  upon 
the  dead  body.  If  the  segment  of  the  colon  that  forms 
the  sigmoid  flexure  and  the  free  part  of  the  rectum  be 
uncoiled  it  will  appear  in  the  form  of  a  large  loop  of 
intestme  extending  from  the  psoas  muscle  to  the  spot 
where  the  rectum  becomes  fixed  opposite  about  the 
middle  of  the  sacrum.  This  loop  has  the  outline  of  a 
capital  omega,  and  is  usually  provided  with  an  exten- 
sive mesentery.  Such  is  occasionally  the  length  of  this 
mesentery  that  the  summit  of  the  omega  loop  can  be 
made  to  touch  the  caecum  or  to  reach  the  level  of  the 
umbilicus.  In  some  examples  I  have  found  this  loop 
to  be  from  eighteen  to  twenty  inches  in  length.  If 
the  lonof  tube  be  introduced  into  such  a  coil  its 
extremity  may  reach  the  level  of  the  umbilicus  and 
yet  not  have  passed  beyond  the  sigmoid  flexure.  In 
one  case  that  I  saw  in  an  emaciated  subject  with 
chronic  obstruction,  the  surgeon  passed  a  long  tube, 
and  demonstrated  with  triumph  that  its  end  could  be 
felt  near  the  umbilicus.  He  maintained  that  the  in- 
strument had  reached  the  centre  of  the  transverse 
colon,  and  that  the  bowel  below  that  point  was  free. 
The  autopsy  that  came  to  pass  in  due  time  revealed 
an  impervious  stricture  of  the  commencement  of  the 
sigmoid  flexure  where  it  joined  the  descending  colon. 
Apart  from  this,  this  present  method  of  diagnosis  takes 
no  account  of  abnormalities  in  the  colon.  Even  if  it 
be  presumed  that  the  sound  has  found  its  way  into 
the  sigmoid  flexure,  it  may  then  have  reached  one  of 
tliose  very  extensive  and  tortuous  coils  that  are  at  times 
found  to  represent  this  segment  of  the  lai'ge  intestine. 
3.  Auscultation  of  the  colon. — This  method 
of  investigating  the  intestine  is  of  much  value,  and  is 
hardly  estimated  at  its  proper  importance. 


Chap.  XXII.]    The  Diagnosis  of  the  Seat.  399 

It  consists  in  auscultating  the  region  of  the  colon 
and  ca?cum  while  fluid  is  being  introduced  into  the 
rectum  by  means  of  an  enema  syringe.  If  the  colon 
be  entirely  clear,  and  the  stethoscope  be  placed  over 
the  caecum,  the  water  can  be  heard  to  reach  that  part, 
and  if  such  be  the  case  pretty  conclusive  evidence  is 
afibrded  that  the  obstruction,  wherever  it  may  be 
placed,  is  at  least  not  in  the  large  intestine. 

I  have  had  several  opportunities,  both  in  the 
healthy  subject  and  in  individuals  suffering  from 
intestinal  olDstruction,  of  testing  the  value  of  this 
method  of  investigation.  In  making  use  of  this  means 
it  is  very  desirable  that  the  surgeon  should  first 
familiarise  himself  with  the  various  sounds  that  may 
be  heai'd  in  the  abdomen,  especially  in  the  subjects  of 
obstruction.  Certain  borborygmi  closely  imitate  the 
noise  made  by  the  enema  as  the  water  passes  along  the 
bowel.  Moreover,  when  the  injection  is  forcibly  ad- 
ministered there  is  some  little  difficulty  at  first  in 
localising  the  sound  it  makes,  since  the  noise  of  the 
rush  of  water  may  be  heard  over  nearly  every  part  of 
the  abdomen.  The  enemata  should  be  quietly  intro- 
duced, and  the  water  injected  be  without  any  admix- 
ture with  air.  If  the  injection  be  made  in  an  inter- 
mittent manner  the  particular  sound  caused  by  the 
enema  may  be  more  readily  differentiated.  The  sound 
of  water  passing  into  theciecum  must  be  distinguished 
from  that  made  by  the  first  rush  of  the  fluid  from  the 
enema  tube  into  the  rectum. 


400 


CHAPTER  XXIII. 

THE  VARIOUS  AFFECTIONS  THAT  HAVE  BEEN  MOST 
FREQUENTLY  CONFUSED  WITH  CASES  OF  OBSTRUC- 
TION   OF    THE    BOWELS. 

A  VERY  large  number  of  diseases  fall  under  this  head, 
and,  indeed,  it  may  be  said  that  there  are  not  very 
many  examples  of  abdominal  disease  that  have  not 
been  confused  at  one  time  or  another  with  cases  of 
intestinal  obstruction. 

A  large  proportion  of  the  examples  of  this  con- 
fusion is  derived  from  records  that  may  now  be 
regarded  as  ancient,  and  deals  with  instances  of  error 
that  could  hardly  be  possible  at  the  present  day. 

To  discuss  every  possible  form  of  mistaken  dia- 
gnosis seriatim  would  involve  more  space  than  this 
work  could  permit,  and  at  the  same  time  produce 
material  that  would  be  of  very  little  value. 

I  propose,  therefore,  to  consider  in  detail  the  two 
morbid  conditions  that  I  think  most  frequently  and 
most  seriously  complicate  the  diagnosis  of  intestinal 
obstruction,  viz.  pseudo-strangulation  and  peritonitis, 
and  then  to  deal  with  the  remaining  causes  of  error 
en  masse,  and  in  as  brief  a  manner  as  possible. 

1.  Pscii€lo-sti'aii$nil:^t><>»* — There  have  been 
recorded  from  time  to  time  certain  cases,  that  collec- 
tively assume  no  inconsiderable  proportions,  where  a 
patient  has  presented  all  the  most  conspicuous  symp- 
toms of  internal  strangulation,  has  died,  and  has 
exhibited  at  the  autopsy  an  intestine  entirely  free 
from  any  mechanical  obstruction. 

There  is  little  doubt  that  these  cases  are  mainly 
due  to   paralysis  of  some   segment  of    the  intestine, 


Chap,  xxiii.]       Errors  in  Diagnosis.  401 

whereby  at  a  certain  spot  the  peristaltic  movements 
cease  and  the  passage  of  the  contents  is  thereby 
aiTcsted.  While  this  condition  may  fully  explain  the 
constipation  observed  in  these  cases,  and  while  that 
constipation  may  in  its  turn  induce  such  symj)toms  as 
vomiting  and  colic,  it  must  at  the  same  time  be 
allowed  that  these  latter  symptoms  are  often  due  to 
reflex  nerve  disturbance,  and  are  thus,  to  a  great 
extent,  independent  of  the  interruption  in  the  peri- 
staltic wave.  This  statement  may  perhaps  be  more 
conveniently  considered  in  connection  with  the 
examples  to  be  given  of  this  form  of  "  obstruction." 

The  subject  of  pseudo-strangulation  of  the  bowel 
was  very  elaborately  dealt  with  by  Henrot  in  an  oft- 
quoted  monograph  that,  although  produced  nearly 
twenty  years  ago,  is  still  to  be  regarded  as  a  master- 
piece.* 

Henrot's  arrangement  of  the  subject  is  (with  some 
trifling  modifications)  still  the  best  that  can  be 
adopted. 

He  divided  all  cases  of  paralysis  of  the  intestine 
leading  to  obstruction  symptoms  into  three  classes: 
(1)  Direct  paralysis  of  a  segment  of  the  gut  due  to 
changes  in  its  walls.  (2)  Indirect  paralysis  depending 
upon  reflex  nerve  action.  (3)  Paralysis  of  the  bowel 
as  a  feature  in  a  general  affection  of  the  nervous 
symptom. 

(1)  Of  this  form  many  examples  may  be  given. 
A  loop  of  intestine  has  been  strangulated  in  a  hernia; 
it  is  reduced  ;  yet  the  symptoms  of  strangulation  per- 
sist ;  the  patient  dies,  and  the  autopsy  reveals  the 
bowel  free  from  any  mechanical  obstruction  and  the 
peritoneum  normal.  Here  it  must  be  surmised  that 
the  involved  coil  has  been  paralysed  as  a  result  of  the 
injuries  sustained  by  its  walls  from  the  strangulation 

*  Des  Pseudo-etranglements,  bv  Dr.  Henri  Henrot.  Paris, 
1865. 

A  A 12 


402  Intestinal  Obstruction.    [Chap.  xxiii. 

and  possibly  also  from  tlie  taxis.  In  sucli  a  case  as 
this  the  persistence  of  symptoms  is  probably  very 
largely  due  to  reflex  action  taking  origin  in  the 
damaged  peritoneum  and  intestinal  walls.  The  nature 
of  this  reflex  disturbance  will  be  discussed  in  dealing 
with  the  second  variety  of  pseudo-strangulation. 
There  are  also  cases  where  the  symptoms  of  obstruc- 
tion have  followed  upon  a  severe  injury  to  the  abdo- 
men, such  as  a  kick  from  a  horse,  and  where  they  may 
be  in  the  main  ascribed  to  a  paralysis  of  the  injured 
portion  of  intestine. 

In  this  category  must  also  be  placed  cases  of 
pseudo-strangulation  due  to  peritonitis,  cases  where 
the  changes  that  spread  to  the  walls  of  the  intestine 
from  the  inflamed  serous  membrane  are  such  that  the 
involved  segment  of  the  gut  is  rendered  incapable  of 
displaying  peristaltic  movements.  "  Furthermore," 
says  Leichtenstern,  in  speaking  of  this  matter,  "  those 
rare  cases  in  which,  during  diarrhoea,  or  tuberculosis 
of  the  intestine,  or  typhoid  fever,  or  in  the  course  of 
a  severe  chronic  intestinal  catarrh,  death  follows  with 
stercoral  vomiting  and  other  symptoms  of  imper- 
meability of  the  intestme,  while  no  mechanical  ob- 
struction can  be  found  at  the  autopsy,  cannot  be 
explained  otherwise  than  by  serous  inflltration, 
degeneration,  and  relaxing  of  the  muscular  coat, 
especially  in  the  neighbourhood  of  large  typhoid, 
tuberculous,  or  dysenteric  ulcers,  leading  to  a  paralytic 
condition  of  the  muscular  coat,  and  thereby  to  arrest 
of  the  advance  of  the  contents  of  the  intestine." 

(2)  In  the  second  class  of  case  we  have  to  do  with 
a  number  of  instances  of  reflex  paralysis,  and  of 
symptoms  due  to  reflex  disturbances  other  than  those 
causing  loss  of  muscular  power. 

But  a  very  limited  inquiry  into  the  subject  of  in- 
testinal obstruction  will  show  that  for  the  production 
of  its  main  symptoms  it  is  by  no  means  necessary  that 


Chap.  XXIII.]      Errors  in  Diagnosis.  403 

the  lumen  of  the  bowel  should  be  considerably  nar- 
rowed. In  Littre's  hernia,  for  example,  only  a  small 
part  of  the  circumference  of  the  gut  need  be  involved 
in  the  strangulation,  and  yet  although  the  lumen  of 
the  bowel  presents  a  free  passage  the  patient  may  die 
with  all  the  symptoms  of  acute  straiigulation. 

It  is  to  be  readily  understood  that  the  bowel  in  the 
immediate  vicinity  of  the  strangulation  may  become 
paralysed  from  more  than  one  cause.  This  paralysis 
may  produce  constipation  and  subsequently  vomiting, 
but  it  can  hardly  be  the  sole  cause  of  the  violent  pain, 
the  severe  vomiting,  and  the  appearance  of  collapse, 
all  of  which  symptoms  may  be  among  the  earliest 
manifestations  of  the  condition.  These  symptoms 
must  be  largely  due  to  reflex  nerve  disturbance  start- 
ing from  the  damaged  nerves  in  the  strangulated  part. 
The  great  nerve  centres  of  the  abdomen  are  excited 
by  the  lesion  j  vomiting  is  produced,  and  violent  and 
disordered  peristaltic  movements  are  set  up.  The 
paralysis  of  the  gut,  which  may  be  due  to  purely  local 
causes,  tends  to  give  to  these  symptoms  somewhat  of 
the  characters  they  present  in  true  intestinal  obstruc- 
tion. 

A  crush  of  the  testicle  is  often  followed  by 
great  collapse  and  with  severe  and  long-continued 
vomiting.  These  symptoms,  which  are  also  so  con- 
spicuous a  feature  in  acute  strangulation,  are  no 
doubt  due  to  a  damage  to  the  spermatic  plexus  which 
arises  so  high  up  in  the  abdomen  as  to  be  in  very  near 
relation  with  the  great  solar  plexus.  Indeed,  a  morbid 
nerve  impulse  could  reach  the  abdominal  nervous 
centres  as  readily  from  the  testicle  as  it  could  from 
such  parts  of  the  colon  as  are  supplied  by  the  inferior 
mesenteric  plexus. 

The  collapse  and  vomiting  that  may  attend  lesions 
of  the  peritoneum  are  of  the  same  character,  and  ara 
also  of  reflex  origin. 


404  Intestinal  Obstruction.    [Chap,  xxiii. 

Pfliigger  found  that  the  moYements  of  the  small 
intestine  could  be  arrested  by  mechanical  irritation  of 
the  skin  of  the  abdomen.  Now  the  integument  over 
the  abdomen  is  supplied  by  certain  dorsal  nerves,  and 
from  the  trunks  of  these  very  same  nerves  are  derived 
the  main  spinal  nerve  contril^utions  to  the  splanchnic 
trunks,  and  these  trunks,  it  is  unnecessary  to  say,  take 
a  very  important  share  in  the  formation  of  the  great 
sympathetic  plexus  in  the  abdomen.  The  connection, 
therefore,  between  an  irritation  applied  to  the  skin  of 
the  belly  and  an  arrest  of  movements  in  the  parts 
supplied  by  the  superior  mesenteric  plexus  is  very 
direct. 

Many  cases  of  pseudo-strangulation  are  not  diffi- 
cult to  interpret  when  viewed  in  the  light  of  the  above 
observations.  Thus  Henrot  *  mentions  a  case  where 
the  symptoms  of  strangulation  of  the  intestine  were 
produced  by  a  phlegmon  of  the  abdominal  parietes. 
In  this  case  the  constipation,  the  colic,  the  vomiting, 
may  all  be  ascribed  to  a  morbid  stimulation  of  certain 
reflex  centres,  the  afferent  impulse  travelling  from  the 
surface  nerves  of  the  abdomen  to  certain  dorsal  nerves, 
and  from  them  to  the  splanchnic  trunks  and  the 
central  plexus  commanding  the  abdominal  viscera. 

As  another  example  of  this  form  of  pseudo-stran- 
gulation I  might  mention  the  case  of  a  male  infant,  to 
whom  my  attention  was  called  by  a  house  surgeon 
who  had  diagnosed  in  the  child  a  strangulated  hernia. 
The  infant  was  in  a  condition  of  great  prostration,  it 
was  troubled  with  incessant  vomiting  ;  there  had  been 
no  action  of  the  bowels  since  the  symptoms  set  in, 
and  there  was  a  fair  degree  of  meteorism.  In  the 
groin  was  a  hard  and  very  tender  irreducible  tumour. 
This,  as  I  soon  discovered,  was  not  a  strangulated 
hernia,  but  an  inflamed  retained  testicle.  Soon  after 
the  application  of  ice  to  the  part  the  child  began  to 
*  Loc.  cit.   page  81. 


Chap.  XXIII.]      Errors  in  Diagnosis.  405 

improve,  and  the  symptoms  of  intestinal  obstruction 
spontaneously  disappeared. 

Henrot's  monograph  contains  many  similar  cases 
in  which  an  inflamed  condition  of  the  testicle  led  to 
some  of  the  chief  manifestations  of  intestinal  obstruc- 
tion. 

In  several  instances  it  would  appear  that  an 
inflamed  hydrocele  has  been  mistaken  for  a  strangu- 
lated hernia.  In  one  instance  no  less  a  surgeon  than 
Dupuytren  was  deceived  by  the  resemblance,  and 
proceeded  to  perform  the  operation  of  kelotomy.*  In 
one  case  reported  in  Henrot's  monograph,  such  grave 
symptoms  analogous  to  those  of  intestinal  obstruction 
followed  the  application  of  a  ligature  to  piles  that  the 
patient's  life  was  threatened. 

In  other  examples  of  this  form  of  pseudo-strangu- 
lation the  exciting  cause  was  an  abscess  or  inflamed 
gland  in  the  region  of  the  groin,  or  a  hernial  sac,  the 
walls  of  which  were  the  seat  of  active  inflammatory 
change.  A  complete  collection  of  these  cases  is  to  be 
found  in  Henrot's  paper. 

(3)  Under  this  head  are  included  cases  of  supposed 
paralysis  of  some  segment  of  the  bowel,  where  the 
local  nerve  lesion  is  but  an  outcome  of  a  more  general 
disturbance  of  the  nervous  centre.  Under  this  class 
are  grouped  cases  of  pseudo-strangulation  occurring  in 
connection  with  hysteria,  meningitis,  etc. 

What  may  be  termed  a  chronic  form  of  the  affec- 
tion has  been  touched  upon  in  the  chapter  on  faecal 
accumulations. 

In  some  of  the  cases  depending  upon  hysteria  the 
symptoms  have  been  quite  acute,  and  have  borne  a 
very  close  resemblance  to  genuine  examples  of  obstruc- 
tion. Dr.  Lusseau  alludes  to  an  instance  of  this  kind, 
where  the  resemblance  was  so  exact  that  an  operation 
for  the  relief  of  intestinal  obstruction  was  proposed. 
*  Clin.  Chir.,  vol.  iii.,  page  584. 


4o6  Intestinal  Obstruction.   [Chap,  xxiii. 

The  patient,  however,  soon  recovered  when  treated 
by  antispasmodics. 

No  especial  rules  can  be  given  for  guidance  in  the 
diagnosis  of  these  cases  of  pseudo-strangulation.  In 
most  instances  there  will  be  no  real  difficulty,  since  a 
condition  may  exist  that  may  be  a  known  cause  of 
obstruction  symptoms,  and  at  the  same  time  there  is 
generally  some  anomaly  in  the  symptoms  themselves, 
some  flaw  in  the  clinical  completeness  of  the  case  that 
may  at  once  suggest  the  spurious  character  of  the 
disorder.  Henrot  and  others  have  written  a  great 
deal  upon  the  means  of  recognising  these  cases,  but 
their  observations  have  little  practical  utility,  and  it 
must  be  owned  that  as  a  knowledge  of  intestinal 
obstruction  extends  so  must  the  number  of  errors  in 
diagnosis  diminish.  It  is  significant  that  the  great 
majority  of  the  examples  of  an  actual  mistake  in  the 
diagnosis  depending  upon  pseudo-strangulation  are  not 
derived  from  recent  records,  but  belong  to  a  period 
when  the  clinical  account  of  intestinal  obstruction  was 
less  comyjlete  than  it  is  at  the  present  day. 

2.  Peritonitis. — The  association  of  acute  peri- 
tonitis with  intestinal  obstruction  is  very  common, 
and,  indeed,  the  inflammation  of  the  serous  membrane 
is  quite  frequently  the  immediate  cause  of  death  in 
obstruction  cases.  Apart,  however,  from  this  asso- 
ciation, it  is  to  be  noted  that  the  symptoms  of  peri- 
tonitis present  many  points  of  resemblance  to  the 
symptoms  of  pure  obstruction  of  the  bowel,  and  so 
close  may  this  resemblance  be  that  the  one  aflection 
may  be  mistaken  for  the  other.  It  will  be  well,  there- 
fore, to  consider  (1)  with  what  clinical  manifestations 
the  a^^pearance  of  diffuse  peritonitis  is  associated  in 
obstruction  cases,  and  (2)  how  cases  of  peritonitis  may 
be  diagnosed  from  cases  of  simple  stoppage  of  the 
bowels  from  mechanical  causes. 

(1)   The  following  are  the  principal  symptoms  that 


Chap.  XXIII.]      Errors  in  Diagnosis.  407 

indicate  the  accession  of  diffuse  peritonitis  in  a  case 
of  intestinal  obstruction.  There  may  be,  in  the  first 
place,  a  rise  of  temperature.  This  symptom  is  by  no 
means  constant,  and  the  development  of  the  serous 
inflammation  may  be  associated  with  a  normal  or  even 
with  a  subnormal  temperature.  Indeed,  I  have  found 
cases  on  record  and  in  hospital  reports  where  the  tem- 
perature, which  was  sinking  when  peritonitis  set  in, 
has  continued  to  fall  after  the  development  of  that 
inflammation.  The  pulse  becomes  smaller  and  more 
thready,  and  increased  in  frequency.  The  abdomen 
becomes  more  distended,  and  it  is  especially  to  be 
noted  that  the  distension  is  uniform.  If  any  coils  of 
intestine  were  visible  before  the  peritonitis  set  in, 
then,  on  the  appearance  of  the  serous  inflammation, 
they  will  cease  to  be  seen.  The  liver  dullness  disap- 
pears, there  is  very  often  increased  dyspnoea  and 
other  evidences  of  pressure  upon  the  thoracic  viscera. 
The  abdominal  parietes,  hitherto  flaccid,  become  hard 
and  tense,  unless  the  patient  be  much  collapsed  or 
deeply  narcotised.  There  is  great  tenderness  on  pres- 
sure all  over  the  abdomen,  and  the  patient,  who  has 
probably  been  restless  and  tossing  to  and  fro  in  bed, 
now  lies  very  still,  and  often  with  the  knees  drawn 
up.  In  cases  associated  with  much  effusion  there  will 
be  evidences  of  the  presence  of  fluid  in  the  more 
dependent  parts  of  the  abdomen.  While  there  is  a 
distinct  and  very  grave  increase  in  the  amount  of  ten- 
derness (which  may,  indeed,  have  been  absent  before 
the  peritonitis)  there  is  not  usually  a  great  increase  in 
the  amount  of  pain.  Owing  to  the  paralysis  of  the 
intestine,  due  to  the  effects  of  the  peritonitis,  the  pain 
depending  upon  irregular  peristaltic  movements  abates, 
such  suffering  as  there  is  becomes  less  paroxysmal,  and 
the  pain,  therefore,  is  more  continuous.  In  many  in- 
stances, therefore,  the  appearance  of  peritonitis  has 
been    attended    by  increased    tenderness     but   hy  a 


4o8  Intestinal  Obstruction.    [Chap. xxiii. 

diminislied  amount  of  paiii.  In  some  cases  tlie  vomiting 
becomes  moi-e  severe,  in  other  examples  it  is  mode- 
rated, and,  if  feculent,  may  become  again  non-ster- 
coraceous.  The  appearance  of  singultus  is  often  asso- 
ciated with  the  onset  of  peritonitis. 

(2)  The  differential  diagnosis  of  peritonitis  and 
intestinal  obstruction. 

The  most  usual  form  of  peritonitis  to  be  mistaken 
for  a  case  of  mechanical  obstruction  is  that  acute  form 
due  to  perforation.  Duplay,  in  an  excellent  mono- 
graph upon  the  subject,  has  collected  no  less  than 
fourteen  recorded  examples  of  this  error  in  diagnosis."^ 

In  each  instance  the  case  was  considered  to  be  one 
of  acute  strangulation  of  the  bowel.  In  several  of  the 
examples  an  operation  was  performed  with  the  inten- 
tion of  relieving  a  supposed  obstruction  and  the  error 
only  discovered  wdien  the  abdomen  had  been  opened. 
The  great  majority  of  the  cases  concerned  j^erforative 
peritonitis  following  upon  some  mischief  in  the  caecum 
or  appendix.  In  two  instances  the  cause  of  the  mis- 
chief was  a  perforation  of  the  gall-bladder.  In  a  case 
of  peritonitis  due  to  this  latter  cause,  reported  by  M. 
Herbelin,  laparotomy  was  performed  under  the  im- 
pression that  the  case  was  one  of  mechanical  obstruc- 
tion, t 

The  reseml)lancc  between  the  cases  of  perforative 
peritonitis  and  those  of  acute  strangulation  is  often 
close.  In  both  the  symptoms  may  develop  suddenly 
during  apparent  health  or  after  certain  vague  ab- 
dominal troubles,  in  both  there  is  early  and  severe 
pain,  in  both  there  is  constipation,  vomiting  that  may 
become  stercoraceous,  and  great  prostration. 

The  following  points  may  be  noticed  in  the  differ- 
ential diagnosis. 

*  Archives  gen.  de  M^J.,  vol.  xxviii.,  1876,  page  513;  and 
ibid.,  187!),  page  709.     [See  aho  Henrot's  monograph.) 
fBull.  de  la  Soc.  Anat.,  July,  1878. 


Chap.  XXIII.]       Errors  in  Diagnosis.  409 

Mode  of  onset. — In  both  it  is  usually  sudden  and, 
in  the  case  of  the  obstruction,  more  commonly  without 
any  definite  preliminary  symptoms.  As  already  noted, 
most  of  the  instances  of  perforative  peritonitis  that 
have  been  the  cause  of  error  have  followed  upon  a 
typhlitis,  or  some  trouble  in  the  appendix.  Now,  in 
these  cases  the  perforation  may  take  place  without 
any  marked  intestinal  symptoms  having  been  noted. 
In  the  majority  of  instances  there  are  symptoms. 
The  bowels  are  irregular,  there  are  attacks  of  severe 
indigestion,  there  is  tenderness  over  the  region  of  the 
csecum.  The  csecum,  distended  with  fsecal  matter, 
may  form  a  distinct  tumour  that  is  the  seat  of  pain, 
and  is  also  tender  on  pressure.  There  may  have  been 
vomiting,  and  very  possil>ly  some  rise  of  temperature. 
In  more  distmct  cases  there  will  be  some  oedema  of 
the  abdominal  parietes  about  the  csecum.  When 
these  symptoms  have  existed  there  should  be  little 
difficulty  in  recognising  the  condition  of  things  when 
at  last  a  perforation  of  the  bowel  occurs. 

A  rigor  may  usher  in  acute  peritonitis,  which  will 
not  be  the  case  in  acute  obstruction. 

The  tem2')erature  in  acute  peritonitis  is  usually  high 
at  first,  falling  again  as  prostration  advances.  In 
certain  examples  attended  by  profound  collapse  tlie  tem- 
perature may  be  subnormal  from  the  first,  but  such 
cases  are  rare,  and  are  not  likely  to  be  confounded 
with  acute  strangulation.  In  those  instances  where 
this  confusion  is  apt  to  occur  there  will  be  almost 
always  a  distinct  elevation  of  temperature  at  the  com- 
mencement of  the  case,  and  this  elevation  may  be 
maintained  through  the  further  progress  of  the  malady, 
only  sinking  to  or  below  normal  at  the  termination. 
In  acute  diffuse  peritonitis  death  may  occur  while  the 
temperature  is  still  at  its  height.  The  earliest  rise  of 
temperature  may  reach  104,  althougli  it  is  more 
usually  not  above  102,  and  throughout  the  progress  of 


4IO  Intestinal  Obstruction.    [Chap,  xxiii. 

the  case  the  temperature  is  apt  to  show  marked  remis- 
sions. In  acute  obstruction  the  temperature  is  low 
at  first,  usually  subnormal,  and  remains  subnormal 
throughout  the  progress  of  the  case. 

Pain. — In  the  inflammatory  affection  the  pain, 
which  may  be  very  severe,  is  attended  by  extreme 
tenderness  upon  pressure.  This  tenderness,  which 
may  be  at  first  local,  soon  becomes  diffused.  In  the 
earlier  stages  of  the  obstructive  affection  there  is  also 
very  severe  pain,  but  there  is  no  marked  tenderness, 
and,  indeed,  the  suffering  is  often  to  be  relieved  by 
pressure. 

Vomiting. — In  both  maladies  vomiting  appears 
early,  but  in  acute  strangulation  it  is  a  much  more 
prominent  symptom  than  in  peritonitis.  In  the  latter 
affection  it  rarely  becomes  feculent,  and  then  only 
towards  the  conclusion  of  the  case.  Among  the  four- 
teen cases  of  acute  peritonitis  collected  by  Duplay  there 
was  feculent  vomiting  in  three  instances  only.  In 
these  fourteen  cases,  as  already  observed,  the  diagnosis 
of  acute  obstruction  had  been  in  each  instance  made. 

Constipation  is  absolute  in  the  obstruction  cases. 
In  peritonitis  it  may  be  absolute  also,  but  not  infre- 
quently a  slight  motion  may  be  passed  or  flatus  may 
be  discharged  by  the  anus. 

The  quantity  of  urine  passed  in  both  the  condi- 
tions may  be  very  small. 

The  abdominal  j^cirietes  are  tense  and  hard  from 
the  first  in  diffused  peritonitis.  In  acute  obstruction 
they  are  flaccid  at  first,  and  often  remain  so  until  peri- 
toneal inflammation  has  set  in. 

The  7neteorism  may  be  localised  at  first  in  the 
obstruction  cases.  It  is  diffused  from  the  commence- 
ment in  peritonitis. 

Cases  of  tubercular  peritonitis  have  been 
mistaken  for  cases  of  obstruction  of  the  bowels.  This 
error  can  but  very  rarely  occur,  for  in  the  most  usual 


chnp.  XXIII.]      Errors  in  Diagnosis,  411 

form  of  tubercular  peritonitis  the  symptoms  have  but 
little  resemblance  to  those  due  to  occlusion.  The 
manifestations  of  the  disease  develop  very  gradually, 
and  the  patients  are  usually  first  seen  when  suffering 
from  great  debility  and  ascites. 

There  is,  however,  an  acute  form  of  the  malady 
which  may  be,  and  has  been,  a  cause  of  error.  In 
this  form  the  disease  commences  acutely  with  a  pain 
in  the  abdomen,  cither  at  a  circumscribed  spot  or  over 
a  larger  area.  Associated  with  it  are  repeated  vomiting, 
constipation,  and  meteorism.  In  a  while  all  the  symp- 
toms may  disappear,  and  then  repeated  attacks  occur 
at  irregular  intervals.  In  this  form  there  is  no  fluid 
effusion."^  M.  Lionville  has  given  a  good  example  of 
mistaken  diagnosis  in  this  variety  of  tubercular  perito- 
nitis. The  subject  was  a  man,  aged  twenty-three, 
who  was  taken  suddenly  with  symptoms  so  severe,  and 
so  like  those  of  intestinal  obstruction,  that  an  opera- 
tion for  his  relief  was  proposed.  In  four  days  the 
bowels  were  opened  spontaneously ;  the  vomiting, 
which  had  been  almost  feculent,  disappeared,  and  the 
patient  returned  to  what  seemed  to  be  a  condition  of 
health.  In  fifteen  days,  however,  the  symptoms  of  in- 
testinal obstruction  appeared  again,  and  again  was  an 
operation  seriously  considered.  The  symptoms,  how- 
ever, passed  off.  The  patient  died  in  three  months, 
and  the  autopsy  revealed  nothing  but  the  ordinary 
evidences  of  tubercular  peritonitis. f 

In  the  differential  diagnosis  of  these  affections  it  is 
especially  to  be  noticed  that  the  tubercular  disorder  is 
attended  by  fever,  and  by  early  and  usually  distinct 
tenderness  of  the  abdomen.  These  symptoms  are 
absent  in  the  obstruction  cases.  After  the  attack 
there  is  usually  a  sense  of  undue  resistance  over  the 

*  Bauer,  Diseases  of  the  Peritoneum.      Ziemssen's  Cyclopaedia 
of  Medicine,  vol.  viii.,  page  328. 

t  Bull,  de  la  Soc.  Anat.  de  Paris,  1875,  page  726. 


412  Intestinal  Obstruction.    [Chap.  xxiii. 

spot  that  lias  been  especially  the  seat  of  pain  and 
tenderness. 

During  the  progress  of  any  case  of  tubercular 
peritonitis,  genuine  intestinal  obstruction  may  occur 
from  matting  together  of  the  coils  of  intestine,  or  from 
bending  or  kinking  of  such  loops  as  are  adherent. 

Diseases  tliat  liave  been  niistakeu  for 
obstruction  of  the  bowels.— Under  this  heading 
I  propose  merely  to  enumerate  a  few  of  the  maladies 
that  have  been  mistaken  for  cases  of  intestinal  ob- 
struction ;  but  not  to  discuss  the  differential  diagnosis 
in  each  instance,  since  many  of  these  examples  of  mis- 
taken diagnosis  have  been  already  referred  to,  and  the 
symptoms  of  each  variety  of  occlusion  have  been,  on 
the  other  hand,  fully  discussed. 

Cholera. — This  disease  has  been  imitated  by  the 
most  acute  forms  of  intestinal  obstruction.  In  these 
cases  the  patient  has  fallen  rapidly  into  a  condition  of 
cholera-like  collapse ;  the  extremities  have  become 
cool,  the  surface  cyanosed,  the  pulse  thready  and 
almost  imperceptible,  the  voice  has  sunk  to  a  whisper, 
and  the  countenance  has  presented  all  the  features  ob- 
served in  cholera.  At  the  same  time  there  has  been  a 
violent  vomiting,  cramps  in  all  the  limbs,  suppression 
of  urine,  and  extreme  prostration.  The  cases  that 
have  most  closely  resembled  cholera  have  been  cases  of 
very  acute  sti'angulation  of  a  considerable  portion  of 
the  small  intestine  es2)ecially  of  the  upper  parts  of 
that  bowel.  The  strangulation  may  have  been  pre- 
ceded by  profuse  diarrhoea,  or  the  gut  below  the  ob- 
struction may  have  been  emptied  by  diarrhoea  after 
the  strangulation  had  occurred."*  In  many  instances 
the  cases  had  been  met  with  during  an  epidemic  of 
cholera. 

Another  form  of  obstruction  that  may  resemble 

*  Fournier  and  Ollivier ;  Gaz.  Med.  de  Paris,  1868.  The 
motions  were  not  arrested  until  two  days  before  death. 


Chap.  XXIII.]      Errors  in  Diagnosis.  413 

cholera  is  ultra-acute  intussusception  associated  pro- 
bably with  much  purging.* 

Dr.  Barlow  mentions  an  instance  where  the  patient 
was  thrown  into  a  choleraic  condition  from  obstruction 
due  to  masses  of  undigested  food.f  A  like  case  of  a 
more  severe  character  is  quoted  in  Dr.  Servier's 
treatise.  In  this  instance  the  patient,  a  soldier,  lived 
only  sixteen  hours  after  the  commencement  of  the 
attack.  \ 

An  excellent  discussion  of  the  chief  features  in  the 
diagnosis  of  these  cases  has  been  afforded  by  M.  Felix 
Refrege.  §  He  deals  with  fourteen  cases  of  error  in 
diagnosis,  and  refers  to  other  but  less  defined  examples. 

In  only  four  of  the  fourteen  cases  were  cramps  in 
the  limbs  noticed,  and  in  all,  save  in  two  examples, 
there  was  absolute  constipation. 

There  can  be  little  real  difficulty  in  the  diagnosis 
if  too  hurried  an  opinion  be  not  arrived  at.  The  ob- 
struction attacks  are  associated  with  intense  pain  at 
the  commencement  attended  by  constipation.  In 
cholera  there  is  an  absence  of  pain  and  profuse  diar- 
rhcea.  The  abdomen  becomes  soon  retracted  in  cholera, 
but  meteoristic  in  acute  strangulation.  In  cholera 
vomiting  does  not  set  in  quite  so  early  as  in  cases  of 
acute  obstruction.  In  many  cases  it  is  entirely  absent, 
and  when  present  is  non-feculent,  and  has  the  peculiar 
whey-like  appearance  so  often  described. 

Error  is  most  likely  to  occur  when  an  example  of 
ultra-acute  occlusion  is  met  with  during  an  epidemic 
of  cholera. 

*  Dr.  Todd;  Med.  Times  and  Gazette,  vol.  ii.,  1865,  page  195. 
M.  Fernet ;  Bull,  de  la  Soc.  Anat.,  1863,  page  296. 

t  Med.  Times,  vol.  i.,  1866,  page  443. 

t  L'Union  Med.,  1867,  i^age  100. 

§  Le  Diagnostic  de  I'Etranglement  intestinal  a  Symptomes 
choleriformes.  These  de  Paris,  1867.  See  also  art.  by  M.  Berger, 
Bull,  et  Mem.  de  la  Soc.  de  Cliir.  de  Paris,  vol.  ii.,  1876,  page 
698  ;  and  Yassor,  These  de  Paris,  1862  ;  and  Savopoulo,  These  de 
Paris,  1854. 


414  Intestinal  Obstruction.    [Chap,  xx hi. 

Lead  colic. — A  case  is  reported  by  Dr.  Fagge"^  of 
a  man,  aged  twenty-nine,  who  had  a  blue  line  on  the 
gums,  but  whose  intestinal  symptoms  were  due  not 
to  lead-poisoning,  as  at  first  supposed,  but  to  partial 
obstruction  from  shrinking  of  the  mesentery. 

Poisoning  by  arsenic. — In  several  instances  cases  of 
acute  strangulation  have  excited  suspicions  of  poisoning 
by  arsenic,  and  the  doubt  has  only  been  cleared  up  at 
the  autopsy.   Leichtenstern  alludes  to  several  examples. 

HejKttic  or  renal  colic  may  be  imitated  by  acute  ob- 
struction in  the  upper  portion  of  the  small  intestine 
associated  with  profuse  non-feculent  vomiting,  intense 
paroxysmal  pain,  collapse,  and  a  retracted  condition  of 
the  abdomen. 

Meningitis. — Dr.  Fagge  alludes  to  a  case  of  acute 
obstruction  of  the  jejunum  where  meningitis  was  sus- 
pected on  account  of  the  delirium,  the  vomiting,  and 
the  retracted  abdomen. 

Cirrhosis  of  the  liver. — Dr.  Lusseau  reports  a  case 
where  cirrhosis  of  the  liver  was  taken  for  an  example 
of  obstruction  of  the  commencement  of  the  colon  by  a 
neoplasm.  The  autopsy,  however,  revealed,  in  addi- 
tion to  the  cirrhosis,  some  old  adhesions  about  the 
caecum  and  sigmoid  flexure,  as  well  as  a  compression  of 
the  third  part  of  the  duodenum  by  an  old  cicatricial 
band,  f 

Cancer  of  the  omentu7u  has  simulated  true  ob- 
struction. X 

A  cyst  of  the  mesentery  has  been  mistaken  for  an 
intussusception  tumour,  §  and  an  intussusception 
tumour  for  a  new  growth  or  a  mass  of  faecal  matter. 

Tumours  formed  by  faecal  masses  have  been  mis- 
taken for  a  number  of  affections  {see  page  354),  and 

*  Guy's  Hospital  Reports,  vol.  xiv.,  page  272. 

+  Progres  Medical,  1879,  page  545. 

X  De  rOcclusion  Intestinale.    These  de  Paris,  1879,  No.  303. 

§  Lull,  de  I'Acad.  de  Med.,  page  831.     Paris,  1880. 


Chap.  XXIV.]  The  Trea  tment  :  Feeding.  415 

notice  has  already  been  taken  of  tlie  numerous  diseases 
which  liave  been  confused  with  chronic  intussuscep- 
tion.    {See  page  237.) 

The  confusion  between  acute  or  subacute  intus- 
susception and  dysentery  or  enteritis  has  been  of  fre- 
quent occurrence. 


CHAPTER  XXIV. 

THE    TREATMENT. 

The  subject  of  the  treatment  of  cases  of  intestinal 
obstruction,  with  its  extensive  bearings  and  its  many- 
vexed  questions,  may  be  most  conveniently  considered 
under  two  general  headings  : 

1.  The    methods  of    treatment    available    for    intestinal 

ohstruction. 

2.  The    special   treatment    of    individual    forms   of    ob- 

struction. 

THE   METHODS    OF    TREATMENT    AVAILABLE    FOE   INTES- 
TINAL   OBSTRUCTION. 

]¥on-operative  measiu^es :  the  feeding  of 
the  patient. — This  is  matter  which  demands  a  little 
more  attention  than  it  has  at  present  received.  In  many 
examples  of  acute  obstruction  the  progress  of  the 
case  is  so  rapid,  and  death  appears  so  early,  that  the 
question  of  supporting  the  patient  by  food  does  not 
require  to  be  entertained.  In  less  rapid  cases,  how- 
ever, this  question  becomes  a  prominent  one,  and  in 
subacute  cases  it  obtains  a  very  considerable  degree 
of  importance.  Certainly  in  not  a  few  instances  one 
of  the  factors  in  the  exliaustion  that  leads  to  death 
depends  upon  the  patient's  inability  to  take  or  to 
retain  food.     When  the  case  has  lasted  four  or  five  or 


41 6  Intestinal  Obstruction.    [Chap.  xxiv. 

six  days  the  patient's  prospect  of  recovery  is  com- 
promised by  the  debility  induced  by  want  of  nourish- 
ment, and  this  debility  may  seriously  modify  the 
result  of  any  operation.  In  not  a  few  instances, 
more  especially  in  cases  of  intussusception,  a  process 
of  spontaneous  relief  is  found  to  be  nearly  complete 
at  the  time  of  death  and  to  have  been  arrested  by 
a  fatal  exhaustion,  to  the  production  of  which  an 
inability  to  take  food  has  no  doubt  contributed.  The 
position  of  acute  and  subacute  cases  of  obstruction 
with  reference  to  the  question  of  feeding  is  as  follows  : 
The  patient  is  very  sick,  he  not  only  vomits  every- 
thing that  he  takes,  but  will  vomit  at  other  times 
than  after  the  ingestion  of  food.  In  many  subacute 
cases,  where  the  sickness  is  not  so  marked,  the  taking 
of  nourishment  excites  the  act  of  vomiting  after  the 
symptom  has  abated,  and  the  patient  may  for 
awhile  only  be  sick  after  he  has  taken  food. 

It  is  obvious  that  it  is  worse  than  useless  to 
attempt  to  feed  these  patients  by  the  mouth.  There 
is  usually  an  entire  lack  of  aj^petite,  and  a  disgust  of 
food  quite  apart  from  the  circumstance  that  every 
mouthful  swallowed  is  apt  to  aggravate  one  of  the 
most  distressing  of  the  symptoms.  Moreover,  even 
if  it  be  supposed  that  the  food  can  be  retained,  it  is 
scarcely  possible  to  imagme  that  it  can  be  digested 
and  absorbed.  The  stomach  is  not  improbably  occu- 
pied by  matters  regurgitated  from  the  bowel.  The 
small  intestine  above  the  obstruction  is  more  or  less 
congested,  is  distended,  is  occupied  by  putrifying 
contents  and  much  flatus,  and  is  certainly  not  in  a 
condition  to  further  elaborate  or  even  to  absorb  any 
food  matters  that  may  reach  it  from  the  stomach. 
These  is  still  one  other  aspect  of  the  question.  In 
some  cases  of  subacute  intussusception  food  may 
occasionally  be  swallowed  without  causing  sickness. 
That  such  food  is  digested  and  al)Sorbed  is  not  very 


Chap. XXIV.]   The  Treatment :  Feeding.  417 

probable.  Whether  it  is  or  not  is  a  little  apart  from 
the  question,  since  clinical  experience  shows  timt  the 
matters,  if  not  rejected,  will  excite  increased  peri- 
staltic action  in  the  intostineS;  and  will  decidedly 
aggravate  the  condition  of  tlie  invagination.  It  is 
obvious^  thei'efore,  that  if  food  is  to  be  administered 
in  these  cases,  it  nmst  be  administered  by  eiiemata 
and  never  by  the  month.  By  ineans  of  nutritive 
enemata  the  patient  may  be  greatly  relieved  an(^ 
his  strength  to  no  small  extent  supported.  The  dis- 
tressing thirst  that  is  often  so  conspicuous  in  cases  of 
acute  obstruction  is  much  abated  by  copious  injections 
of  fluid  into  the  rectum,  and  when  more  substantial 
nourisliment  needs  to  be  administered,  it  can  be 
introduced  by  means  of  small  and  repeated  enemata 
of  peptonised  foods.  In  the  majority  of  the  cases  of 
acute  obstruction,  the  small  intestine  is  the  p,ii-t 
involved,  and  the  colon,  therefore,  is  free  and  capable 
of  receiving  injections.  Even  in  cases  of  acute  ob- 
struction involving  the  colon  (as  in  volvulus  of  the 
sigmoid  flexure),  enemata  may  be  retained  by  the 
rectum,  althoug-h  in  many  of  these  cases  there  i,^  so 
much  tenesmus  that  feeding  by  this  method  is  im- 
possible. On  the  other  hand,  it  must  be  remembered 
that  the  vomiting  in  cases  where  the  colon  is  involved 
is  usually  much  less  severe  than  it  is  when  the  ob- 
struction implicates  the  lesser  bowel. 

There  are  many  circumstances,  however,  besides 
the  one  already  mentioned,  under  which  the  admini- 
stration of  food  by  enemata  is  not  possible.  In 
many  examples  of  intussusception  it  is  not  possible. 
The  invagination  has  reached  the  lower  colon,  there  is 
tenesmus,  the  contents  of  the  bowel  are  being  fre- 
quently rejected  by  a  species  of  diarrhcea,  and  enemata 
merely  aggravate  the  peristaltic  movements  of  the 
tube.  In  these  cases,  however,  that  are  associated 
with  diarrhcea,  there  is  oftexi  comparatively  little 
B  B — 12 


4l8  IXTESTINAL    OBSTRUCTION.      [Chap.  XXIV. 

vomiting,  and  the  patient  is  not  infrequently  able  to 
take  a  little  nourishment  by  the  mouth  without  in- 
convenience being  caused. 

There  are  other  cases  of  obstruction  apart  from 
intussusception,  where  the  administration  of  enemata 
has  been  undesirable  on  account  of  the  disturbance 
produced,  the  mere  injection  having  caused  in  such 
instances  an  increase  in  the  vomiting,  and  in  the  pain 
depending  upon  peristaltic  movements. 

In  acute  and  subacute  cases  of  obstruction,  the 
question  of  feeding  the  patient  resolves  itself  to  this  : 
the  patient  may  have  ice  to  suck  to  relieve  the  sense 
of  distressing  thirst,  but  apart  from  this  all  food 
should  be  administered,  if  possible,  by  the  rectum,  and 
in  any  case  this  method  of  taking  nourishment  should 
be  persevered  with  so  long  as  it  can  be  carried  out. 

In  chronic  intestinal  obstruction,  and  especially 
in  cases  where  the  small  intestine  is  the  part  in- 
volved, the  feeding  of  the  patient  becomes  a  matter 
of  extreme  importance,  and  one  demanding  consider- 
able attention. 

In  this  form  the  lumen  of  the  intestine  is  only 
partially  occluded.  Matters  can  pass  readily  througli 
it  so  long  as  they  are  fluid,  or  at  least  of  quite  soft 
consistence  ;  but  any  large  solid  particles  passing  along 
the  bowel  will  certainly,  if  of  sufficient  magnitude, 
plug  the  stenosed  part  and  produce  severe  symptoms. 
This  circumstance  is  repeatedly  illustrated  in  the 
clinical  history  of  stricture  of  the  intestine.  Indeed, 
the  earlier  symptoms  of  stenosis  of  the  small  intestine 
depend  upon  an  occasional  entire  occlusion  of  the  tube, 
and  this  occlusion  is,  in  the  majority  of  cases,  due, 
directly  or  indirectly,  to  the  presence  of  masses  of 
undigested  food.  The  earlier  treatment  of  stricture 
of  the  small  intestine  resolves  itself  almost  solely  into 
a  question  of  diet.  So  long  as  the  patient  exercises 
extreme  care  in  the  selection  of  his  food,  so  long  will 


Chap.  XXIV.]   The  Treatment :  Feeding.  419 

he  remain  free  from  severe  trouble  until  such  time  as 
the  condition  of  the  stricture  will  not  permit  the  free 
passage  of  even  well-digested  matters.  In  examples 
of  stenosis  of  the  colon  the  sam^i  importance  attaches 
to  diet,  although  it  may  be  not  quite  so  manifest. 
In  these  cases  there  may  be  no  aggravation  of  sj^mp- 
toms  shortly  after  food,  the  connection  between  the 
taking  of  certain  foods  and  the  appearance  of  certain 
symptoms  may  be  not  so  direct  as  in  cases  of  stricture 
of  the  lesser  bowel,  but  the  relationship  still  exists. 
The  more  solid  the  contents  of  the  colon  become,  the 
more  trouble  does  the  stricture  produce,  and  it  is 
needless  to  point  out  the  connection  between  the  state 
of  the  colic  contents,  and  the  nourishment  that  has 
been  ingested.  In  the  long  period  that  xisually 
elapses  between  the  commencement  of  symptoms  and 
the  time  when  operative  interference  has  to  be  con- 
sidered, a  very  great  deal  may  be  done  by  a  careful 
dieting  of  the  patient.  Indeed,  during  this  period 
the  treatment  of  the  case  is  in  the  main  a  pure 
question  of  dieting. 

These  observations  apply  of  course  to  feeding  by 
the  mouth,  and  refer  to  cases  of  stricture  as  well  as  to 
others  allied  to  that  condition.  In  the  later  stages  of 
these  forms  of  obstruction,  when  vomiting  becomes  a 
more  frequent  and  prominent  symptom,  the  question 
of  administering  some  or  (for  a  while)  all  of  the  food 
by  enemata  again  arises. 

In  no  case,  however,  do  I  think  that  operative 
measures  should  be  delayed  on  account  of  the  cir- 
cumstance that  the  patient's  general  strength  can 
be  fairly  supported  by  nutrient  enemata.  When 
operation  is  desirable  on  account  of  the  condition  of 
the  bowel  it  should  be  carried  out,  and  the  more 
favourable  the  patient's  general  state  at  the  time  of 
the  operation,  the  greater  degree  of  success  may  be 
expected  to  attend  the  procedure. 


42 o  Intestinal  Obstruction,     rch.-ip.xxiv. 

In  not  a  few  examples  of  chronic  intussusception 
tlie  patient  dies  of  marasmus  and  exha,ustion.  This 
termination  is  in  great  part  brought  about  by  the 
enfeebling  effect  of  persistent  vomiting  and  frequent 
pain,  but  it  depends  also  in  a  large  degree  upon  the 
malnutrition,  consequent  upon  the  inability  to  take  or 
to  retain  food,  or  to  absorb  nutritive  matters  from  the 
disordered  bowel  above  the  invagination.  In  many  of 
these  cases  the  general  strength  may  be  supported  by 
peptonised  enemata,  and  the  patient's  life  greatly 
prolonged  in  instances  where  operative  interference 
is  not  considered  as  necessary.  In  cases  where  an 
operation  may  be  performed,  the  success  of  the  pro- 
cedure is  likely  to  be  rendered  more  certain  by  the 
improved  state  of  nutrition  consequent  upon  feeding 
by  the  rectum.  There  are,  of  course,  cases  of  chronic 
intussusception  in  which  the  repeated  use  of  even 
small  injections  would  not  be  tolerated. 

Opiiiiii. — There  is  certainly  no  one  drug  of  more 
use  and  value  in  cases  of  intestinal  obstruction  than 
opium.  The  precise  action  of  opium  upon  the  intesti- 
nal movements  may  be  still  a  matter  of  some  scientific 
speculation,  although  its  gross  effects  in  cases  of  intes- 
tinal disorder  are,  from  a  clinical  point  of  view,  obvious 
enough.  The  latest  experimental  investigations  upon 
this  subject  are  those  conducted  by  Nothnagel.  The 
following  abstract  from  an  article  in  the  Lancet*  gives 
tlie  general  result  of  these  experiuients  in  a  very  brief 
and  complete  manner.  Nothnagel  "  discovered  in 
his  earliest  experiments  that  a  sodic  salt  placed  in 
contact  with  the  outer  surface  of  the  intestine  of  a 
rabbit  causes  a  local  contraction  which  passes  upwards. 
This  effect  was  found  to  be  prevented  by  a  preceding 
subcutaneous  injection  of  a  small  quantity  of  morphia, 
one  to  four  centigrammes.  Even  bicarbonate  of 
soda,  which  under  normal  circumstances  causes  a  very 
*  Leading  article,  I/ancet,  Oct.  2lst,  1882,  pa§e  672, 


Chap.  XXIV.]    The  Treatment:  Opium.  421 

energetic  contraction,  no  longer  produces  the  effect. 
Nothnairel  ascribes  the  effect  to  the  stimulation  of 
a  nervous  mechanism  antagonistic  to  that  which  is 
excited  by  the  sodic  salt.  If,  however,  a  much  larger 
quantity  of  morphia  was  injected  (ten  centigrammes, 
for  instance),  not  only  does  the  sodic  salt  produce  its 
customary  effect,  but  the  contraction  is  much  more 
energetic  than  under  ordinary  circumstances.  Tliis 
anomalous  effect  seems  to  indicate,  that  while  small 
doses  of  morphia  stimulate,  larger  doses  paralyse  the 
inhibitory  nervous  mechanism.  Morphia  appears  thus 
to  exert  on  the  intestinal  apparatus  an  action  compa- 
rable to  that  which  digitalis  exercises  on  the  innerva- 
tion of  the  heart,  which  consists  in  a  stimulation  or 
paralysis  of  the  inhibitory  fibres  of  the  vagus,  accord- 
ing to  the  dose  employed.  Other  experiments  seem  to 
show  that  the  action  of  morphia  on  the  intestine  is 
exerted  through  the  splanchnic  nerves.  The  consti- 
pation produced  by  morphia  is  assumed  to  be  the  re- 
sult of  a  stimulation  of  the  inhibitory  fibres  contained 
in  the  nervous  trunk,  aided  by  a  diminution  in  the  in- 
testinal secretion." 

As  to  how  far  these  experiments  are  confirmed  or 
refuted  by  clinical  experience  in  the  human  subject  it 
is  needless  here  to  enquire.  The  general  efi'ect  of 
opium  in  cases  of  intestinal  obstruction  is  very  marked, 
and  very  fairly  constant  when  the  conditions  under 
which  its  action  is  observed  are  equal.  It  allays  pain. 
It  can  dull  or  remove  the  severe  agony  that  often 
marks  the  earliest  stasfes  of  acute  strano'ulation.  It 
can  quiet  the  constant  sense  of  distress  that  attends 
upon  a  case  of  chronic  obstruction. 

Pain,  moreover,  may  often  be  taken  as  a  mea- 
sure of  shock,  especially  in  examples  of  collapse 
depending  upon  intestinal  lesions,  and  with  the  sub- 
sidence of  pain  the  more  striking  manifestations  of 
shock  commonly  disappear.    Thus  in  acute  cases  the 


42  2  Intestinal  Obstruction.     [Cba?.  xxiv. 

effect  of  opium  in  moderating  and  even  removing 
the  more  conspicuous  symptoms  of  shock  is  often 
very  pronounced.  It  not  only  affects  the  pain, 
but  it  influences  the  pulse  and  temperature.  One 
of  the  cases  reported  by  Leichtenstern  in  his  mo- 
nograph maybe  taken  in  illustration  of  this.  "A 
few  days  ago  I  saw,"  he  writes,  "  an  unusually  severe 
case  of  obstruction  by  gall  stones  ;  the  patient  was 
covered  with  cold  sweat,  had  cool  extremities,  muffled 
voice,  choleraic  countenance,  vomited  freely,  and  pre- 
sented a  board-like  tension  of  the  abdomen.  The 
temperature  in  the  rectum  was  95|^° ;  a  thermo- 
meter j^laced  at  the  same  time  in  the  axilla,  and 
compared  with  the  one  in  the  rectum,  marked  only 
92S;  the  pulse  was  small,  its  frequency  48  in  the 
minute.  After  an  injection  of  morphia,  the  tension  of 
the  abdomen  diminished,  the  skin  filled  with  blood, 
the  pulse  rose  gradually  to  76,  the  temperature  in 
the  rectum,  after  the  patient  had  passed  an  hour  of 
comparative  comfort,  was  99-6^."^  Besides  all  this, 
in  such  cases  the  expression  of  the  face  returns  more 
to  its  normal  condition.  The  pinched  appearance  is 
gradually  lost,  the  eyes  appear  less  sunken,  and  the 
lips  less  blue.  The  dry  tongue  becomes  moist,  the 
sweat  ceases  to  pour  from  the  face,  the  intellectual 
faculties  revive,  and  the  patient  passes  from  a  state  of 
intense  terror  and  anxiety  to  a  condition  of  compara- 
tive repose.  I  have  no  doubt  that  in  many  severe 
cases  a  death  early  in  the  case  from  shock  has  been 
averted  by  the  timely  injection  of  morphia.  Upon  the 
quantity  of  the  urinary  secretion  the  effects  of  opium 
aA-e  often  very  marked,  as  many  reported  cases  testify. 
Before  the  administration  of  the  drug,  and  during  the 
presence  of  the  collapse  symptoms,  there  may  be 
oliguria  or  apparent  suppression  of  urine,  but  after  the 
administration  of  the  narcotic  a  copious  secretion  of 
*  Ziemssen's  Cyciopicciia  oi  Medicine,  vol.  vii. ,  page  49U. 


Chap.  XXIV.]     The  Treatment :  Opium.  423 

urine  is  one  of  the  commonest  evidences  of  its  bene- 
ficial effects. 

Some  of  the  symptoms  of  intestinal  obstruction, 
such  as  violent  and  disordered  peristaltic  movements 
and  vomiting,  depend  in  a  great  degree  upon  reflex 
nerve  action.  Opium  has  large  powers  as  an  inhibitor 
of  reflex  movements.  Thus  it  happens  that  under 
the  influence  of  the  drug  the  vomiting,  especially  in 
acute  cases,  often  exhibits  a  singular  improvement, 
and  the  movements  of  the  bowels  become  almost 
stilled.  In  chronic  cases,  where  the  intestinal  move- 
ments can  be  observed  through  the  parietes,  the  in 
fluence  of  the  narcotic  upon  those  movements  is  very 
conspicuously  displayed.  If  one  considers  the  serious 
part  that  peristalsis  takes  in  the  development  of 
intestinal  obstruction  it  will  be  understood  that  any 
moderation  in  this  movement  is  likely  to  be  attended 
by  great  improvement.  This  circumstance  is  strik- 
ingly illustrated  by  the  following  case  placed  upon 
record  by  M.  Le  Fort :  A  young  man  received  a 
kick  upon  the  belly  from  a  horse.  Some  days  after 
he  developed  symptoms  of  internal  strangulation. 
Opium  was  at  once  administered  every  one  or  two 
hours.  The  symiptoms  passed  away.  The  patient's 
appetite  returned ;  his  bowels  were  freely  opened ; 
he  got  up.  Before  long,  however,  gurgling  would 
begin  in  the  abdomen  associated  with  energetic  move- 
ments of  the  intestine  and  subsequently  with  much 
meteorism.  These  symptoms  were  soon  followed  by 
vomiting,  pain,  and  the  other  evidences  of  intestinal 
obstruction.  Under  the  influence  of  opium  all  these 
symptoms  subsided  and  the  patient  was  soon  well 
again.  Within  two  months  the  patient  had  three 
attacks  of  internal  strangulation  which  yielded  to 
opium.  The  fourth  attack  was  associated  with  perito- 
nitis, of  which  he  died.  The  autopsy  revealed  two 
hernise  of  the  small  intestine  through  two  rents  in  the 


42  4  Intestinal  Obstruction.      [Chap.  xxiv. 

great  omentum,  whicli  rents  were  no  doubt  produced 
at  the  time  of  the  accident.  Here  it  would  seem  that 
while  the  intestines  were  still,  and  their  contents 
quietly  jDropelled,  the  narrowing  of  the  gut  was  not 
sufficient  to  cause  obstruction.  But  when  the  peri- 
staltic movements  became  active  and  the  contents  were 
hurried  along,  the  involved  coils  became  obstructed 
and  symj)toms  were  immediately  produced.* 

The  value  of  opium  in  the  treatment  of  intussus- 
ception can  scarcely  be  over-estimated.  In  this  con- 
dition the  very  origin  of  the  invagination  as  well  as 
its  progress  depend  upon  disordered  peristaltic  move-: 
ments.  Some  of  the  most  distressing  symptoms  of  the 
affection  are  due  to  those  movements.  Opium  arrests 
them.  When  the  patient  is  fully  under  the  influence 
of  the  drug  the  intestines  would  appear  to  be  still,  an 
increase  of  the  intussusception  is  scarcely  possible,  and 
the  troubled  parts  have  all  the  advantages  of  phy- 
siological rest.  When  once  the  irregular  peristaltic 
movements  are  brought  into  abeyance  a  most  favour- 
able opportunity  is  offered  to  the  part  to  return  to  its 
normal  condition.  I  have  not  the  least  doubt  that 
many  cases  of  acute  intussuscejjtion  have  yielded  to 
the  early  administration  of  opium,  and  it  is  not  im- 
probable that  many  of  the  examples  of  the  "  cure  "  of 
acute  strangulation  by  opium  Ijelong  really  to  this 
pathological  division. 

Not  a  few  instances,  however,  are  reported  of  cases 
of  obstruction  that  have  spontaneously  yielded  under 
the  ejQTects  of  opium,  in  which  there  is  no  reason  to 
suppose  that  the  cause  of  the  obstruction  w^as  an  inva- 
gination. As  examples  of  this  may  be  cited  the  fol- 
lowing :  Mr.  Brewer  records  the  case  of  a  man,  aged 
forty-nine,  who  presented  the  symptoms  of  acute  ob- 
struction. The  condition  was  ascribed  to  a  too 
hearty  meal  of  steak-j)udding.  Aperients  were  at  first 
*  Bull,  et  3Iem.  de  la  Soc.  de  Chir.  de  Paris,  1879,  page  635. 


Chap,  xxiv.i     The  Treatment :  Opium.  4^^ 

administerecl,  but  only  with  the  effect  of  increasing 
the  trouble.  The  subsequent  treatment  consisted  of 
opium,  the  use  of  enemata,  and  poultices.  The 
enemata  had  no  effect,  and,  indeed,  provoked  vomit- 
ing. The  action  of  the  poultices  may  be  con- 
sidered as  nil,  and  the  treatment  therefore  is  reduced 
to  rest  and  opium.  The  man  had  all  the  symptoms  of 
internal  strangulation,  the  vomiting  was  severe  and 
became  stercoraceous.  There  was  absolute  constipa- 
tion for  eleven  days.  At  the  end  of  that  time  a 
motion  was  passed  spontaneously  and  the  patient 
made  a  rapid  recovery.* 

In  another  case,  less  fully  reported,  a  female,  aged 
thirty-nine,  after  long-continued  pain  in  the  epigas- 
trium began  to  vomit  and  to  suffer  from  complete 
constipation.  The  vomiting  was  severe  and  was  for 
seventeen  days  stercoraceous.  Indeed,  one  note  during 
the  progress  of  the  case  states  that  the  patient  vomited 
four  to  live  pints  of  feculent  matter  every  twenty- 
four  hours.  Xo  aperients  were  given.  The  only  treat- 
ment adopted  consisted  in  the  use  of  opium  and  the 
administration  of  enemata.  The  latter  produced  no 
effect.  At  last  the  bowels,  after  having  been  absolutely 
obstructed  for  nineteen  days,  were  opened  sponta- 
neously and  the  patient  made  a  good  recovery.! 

The  immense  quantity  of  morphia  that  can  be 
tolerated  in  some  chronic  cases  is  surprising.  Dr. 
Blake  reports  the  case  of  a  man  whose  bowels  were 
absolutely  confined  for  no  less  a  time  than  eighteen 
weeks.  He  began  early  in  the  case  to  take  morphia, 
and  before  its  conclusion  was  taking  twelve  grains  of 
the  alkaloid  every  day.  The  bowels  were  sponta- 
neously relieved  before  death,  which  occurred  seven 
days  after  this  relief  of  the  obstruction. 

While  opium  is  of  great  value  in  relieving  the  more 

*  Lancet,  vol.  ii.,  1874,  page  726. 

t  Ibid.,  vol.  i.,  18G8,  page  284;  case  by  JIi-.  Moses. 


426  Intestinal  Obstruction.      [chap.  xxiv. 

urgent  and  distressing  of  the  symptoms,  it  must  also 
be  observed  that  its  use  may  seriously  obscure  the 
diagnosis  in  an  obscure  case  of  acute  strangulation. 
It  may  so  modify  the  symptoms  and  so  aifect  the 
general  aspect  of  the  case  that  the  more  characteristic 
manifestations  of  the  malady  are  put  entirely  in  abey- 
ance. If  the  pain  be  modified  or  relieved,  if  the 
symptoms  of  collapse  be  but  dimly  marked,  if  the 
vomiting  be  slight  and  of  little  moment,  and  if  the 
patient  appear  to  be  in  a  state  of  comparative  ease, 
some  of  the  chief  factors  in  a  proper  differential 
diagnosis  will  be  wanting.  This  is  well  illustrated  in 
cases  of  strangulated  hernia,  especially  in  old  persons. 
The  symptoms  may  in  these  cases  be  at  first  typical 
enough,  but  when  opium  is  administered  they  become 
not  only  obscured  but  misleading.  The  evidences  of 
pain  and  prostration  become  indistinct,  the  dry  tongue 
becomes  moist,  the  pulse  improves,  the  excretion  of 
urine  is  normal,  the  abdomen  is  the  seat  of  no  severe 
pain,  the  hernia  is  not  especially  tender,  the  vomiting 
has  ceased  or  has  become  very  much  diminished.  In 
short,  the  patient's  symptoms  have  apparently  im- 
proved, while  the  state  of  the  herniated  bowel  has  be- 
come worse  and  worse.  I  have  twice  had  under  my 
care  in  the  London  Hospital,  elderly  patients  with 
strangulated  herniae,  who  had  been  freely  drugged  with 
opium  before  admission,  and  who  had  lost  most  of  the 
more  conspicuous  evidences  of  strangulation.  In  both 
there  was  great  prostration,  in  both  there  was  an 
absence  of  pain,  in  both  the  vomiting  had  become 
much  less  marked  than  it  had  been,  and  in  both  the 
hernial  tumour  was  becoming  soft  through  gangrene. 

In  like  manner,  in  cases  of  internal  strangulation, 
the  symptoms  may  be  so  improved  and  so  modified 
by  the  free  administration  of  opium  that  the  clinical 
outline  of  the  case  may  become  greatly  blurred  and 
serious  errors  in  the  diagnosis  result  in  consequence. 


Ch::p.  XXI V.J  ThE    TREATMENT :    APERIENTS.  427 

I  think  that  in  acute  cases  the  use  of  opium  should 
be  conducted  with  the  greatest  possible  caution  before 
a  definite  diagnosis  has  been  made,  or  before  a  definite 
plan  of  treatment  has  been  decided  upon.  When  once 
the  drug  has  been  given  the  clinical  aspect  of  the 
case  may  become  greatly  altered  without  any  corre- 
sponding beneficial  change  taking  place  in  the  involved 
portion  of  intestine.  No  better  rules  can  be  adopted 
in  this  matter  than  those  that  guide  the  surgeon  in 
the  use  of  opium  in  strangulated  hernia. 

Aperients. — There  are  comparatively  few  cases 
of  intestinal  obstruction,  in  the  sense  in  which  the 
term  is  used  in  the  present  volume,  that  are  not 
greatly  aggravated  by  the  use  of  aperient  medicines. 
In  all  cases  of  acute  and  of  subacute  strangulation 
their  use  is  to  be  absolutely  condemned  without 
reservation.  They  merely  excite  increased  peristaltic 
action  in  such  cases,  and  aggravate  all  the  symptoms, 
increasing  the  pain,  rendering  the  vomiting  more 
severe,  and  producing  without  doubt  a  more  grave 
condition  of  strangulation. 

Fortunately,  in  most  of  the  acute  cases  the  aperient 
is  at  once  vomited  when  taken;  but  when  it  is  retained, 
or  when  croton  oil  is  used,  or  when  the  aperient  drug 
is  administered  by  an  enema,  it  can  only  be  said  that 
it  does  unmixed  harm.  In  a  great  many  instances 
the  symptoms  have  not  become  severe  until  after  the 
administration  of  a  purge.  Vomiting  that  had  been 
moderate  and  merely  bilious  has  become  profuse  and 
feculent  after  the  use  of  an  aperient.  Profound 
collapse,  from  intense  pain,  has  also  followed  this 
treatment,  and  it  has  in  many  instances,  I  think, 
brought  about  a  threatening  perforation  of  the  bowel. 
Aperient  medicines  in  these  maladies  have  rendered 
subacute  cases  acute,  and  have  caused  chronic  forms 
of  obstruction  to  take  on  an  acute  development. 
Indeed,  among  the  indirect  causes  of  dea,th  in  stoppage 


42 S  Intestinal   Obstruction.     [Cbap.  xxiV. 

of  tlie  bowels  purges  Would  occupy  a  very  prominent 
position,  if  all  the  cases  where  they  have  been  used 
could  be  brought  to  light.  The  evil  effect  of  aperients 
in  cases  allied  to  those  now  under  notice  is  well  sho^vn 
in  an  instance  of  injury  to  the  abdomen  reported  by 
Mr.  Simon.*  A  man,  aged  sixty,  was  ridden  over, 
and,  as  an  autopsy  showed,  his  jejunum  was  partially 
ruptured.  No  extravasation,  however,  appears  to 
have  taken  place  at  or  immediately  after  the  accident. 
For  seventy  hours  the  patient  remained  free  from  any 
symptom  of  abdominal  trouble.  He  had  then  several 
doses  of  ajDerient  medicine.  Symptoms  of  perforative 
peritonitis  very  rapidly  developed,  and  the  j^atient 
died.  In  this  case  the  death  of  the  individual  may 
be  fairly  ascribed  to  the  effect  of  the  treatment. 

In  acute  and  subacute  forms  of  intussusception, 
also,  aperients  can  do  little  but  harm.  They  simply 
excite  increased  peristaltic  movement  and  greatly 
aggravate  the  local  condition.  In  not  a  few  instances 
that  have  been  reported  the  use  of  an  aperient  has 
evidently  determined  the  strangulation  of  an  intus- 
susception, and  has  very  seriously  compromised  the 
future  prospects  of  the  case. 

In  volvulus  of  the  sigmoid  flexure  and  of  other  parts 
it  is  needless  to  say  that  aperients  do  infinite  harm, 
and  tend  to  increase  rather  than  to  diminish  the  dis- 
tortion of  the  bowel. 

In  obstruction,  however,  due  to  fnecal  accumula- 
tion, aperients  are  of  especial  value,  particularly  when 
combined  with  enemata  and  administered  with  proper 
caution.  In  cases  also  of  chronic  obstruction  depend- 
ing upon  partial  mechanical  occlusion  of  the  bowel, 
laxatives  cautiously  administered  are  often  of  the 
greatest  service.  They  render  the  intestinal  contents 
fluid  and  prevent  accumulations  above  the  obstruc- 
tion. Violent  aperients  are,  however,  often  almost  as 
*  Path.  Soc.  Trans.,  vol.  iv.,  1853,  page  151. 


Chap,  xxiv]   The   Treatment :  Aperients.         429 

obnoxious  in  these  cases  as  they  are  in  examples  of 
acute  strangulation.  They  hurry  along  the  contents 
and  rapidly  plug  the  stenosed  segment,  at  the  same 
time  that  they  roughly  disturb  the  disordered  bowel 
above  the  obstruction.  It  must  be  noted  that  the  in- 
testine above  the  obstruction  is  often  hypersemic  and 
in  a  condition  far  from  healthy,  and  that  a  violent  irri- 
tation applied  to  such  a  segment  of  bowel  may  lead 
to  serious  changes  within  its  walls.  Indeed,  in  the 
following  case  I  think  it  may  not  be  unjust  to  ascribe 
the  patient's  death  to  the  aperients  that  she  took, 
A  woman,  suffering  from  long- continued  constipation, 
depending  upon  a  non-malignant  stricture  of  the 
sigmoid  flexure,  took  castor-oil  and  other  powerful 
drastic  purgatives.  This  treatment  led  to  no  improve- 
ment, but  induced  a  profuse  diarrhoea  attended  by 
great  prostration  and  soon  followed  by  death.  The 
autopsy  revealed  the  circumstance  that  the  greater 
part  of  the  anterior  wall  of  the  ascending  colon  had 
sloughed,  faecal  extravasation  being  only  prevented  by 
the  adhesion  of  the  omentum  over  the  necrosed  part."^ 
In  many  cases  of  chronic  intussusception  the 
occasional  and  cautious  use  of  gentle  laxatives  is  of 
much  service  as  a  palliative  measure.  The  aperient 
in  these  cases  can  render  fluid  the  intestinal  contents 
and  can  clear  the  bowel  more  or  less  efficiently 
without  leading  to  an  amount  of  peristalsis  that  may 
do  harm  to  the  invaginated  part.  Dr.  Wilks  has 
recorded  a  case  which  he  reports  as  an  example  of 
intussusception  cured  by  purging.  The  patient  was 
a  girl,  aged  thirteen,  who  suffered  for  some  forty 
days  wdth  intestinal  symptoms  associated  with  ths 
presence  of  a  tumour  in  the  right  hypochondrium. 
Purges  were  administered,  the  bowels  were  evacuated, 
the   tumour  gradually  disappeared,  and  the   patient 

*  Case  by  Dr.  Moiion  :  Path.  Soc.  Trans. ,  vol.  xx. ,  1869,  page 
181,  ^ 


43°  Intestinal  Obstruction.    [Chap.  xxiv. 

recovered.*  With  every  respect  for  the  authority  of 
so  eminent  a  physician,  I  would  submit  that  the  symp- 
toms in  this  case  do  not  very  clearly  point  to  chronic 
intussusception.  Indeed,  the  whole  circumstances  of 
the  case  could  be  more  readily  associated  with  the 
notion  of  a  faecal  accumulation,  a  diagnosis  that  Dr. 
Wilks  especially  repudiates.  The  conception  of  an 
invagination  that  could  be  actually  cured  by  purga- 
tives invoh'ing  a  great  increase  in  the  peristaltic 
movements  is  not  consistent  with  the  usually  accepted 
ideas  as  to  the  pathogenesis  of  the  disease. 

Metallic  iiiercHry.— The  use  of  metallic  mercury 
in  large  doses  is  of  very  ancient  date,  and  the  metal  was 
at  one  time  regarded  as  a  most  important  and  certain 
remedy.  In  those  days  little  was  known  of  the  patho- 
logy of  intestinal  obstruction ;  most  of  the  acute  cases 
were  put  down  to  "  volvulus,"  and  the  mercury  was 
supposed  by  its  mere  weight  to  undo  some  twist  of  the 
bowel  that  was  causing  obstruction,  or  to  force  open  a 
passage  that  had  been  temporarily  closed.  Many  cases 
are  reported  where  patients  suffering  apparently  from 
severe  ileus  were  immediately  relieved  by  a  large  dose 
of  quicksilver.  It  is  needless  to  say  that  this  mode  of 
treatment  has  gone  more  or  less  out  of  use,  and  the 
subject  would  hardly  have  merited  a  notice  were  it 
not  for  a  very  able  monograph  recently  published  by 
M.  Matignon,  wherein  this  mode  of  ■  treatment  is  once 
more  advocated.!  Under  any  circumstances  M. 
Matignon's  paper  cannot  fail  to  be  read  with  consider- 
able interest,  and  it  is  from  this  production  that  the 
remarks  that  follow  are  in  the  main  adduced. 

The  cases  for  which  this  mode  of  treatment  are 
best  adopted  are  cases  of  obstruction  due  to  stercoral 
tumours  and  some  exaxnples  of  obstruction  depending 

*  Lancet,  vol.  i,,  1870,  page  731. 

t  Du  Traitement  de  I'Occlusion  intest,  jiar  le  Mercure  m^tal- 
lique  a  Haute  Dose.    These  de  Paris,  No.  340,  1879. 


Ciiap.  XXIV.]    The  Treatment:  Mercury.  431 

upon  the  accumulation  of  fsecal  matters  above  a  stric- 
ture or  stenosed  part.  In  all  cases  of  acute  and  sub- 
acute strangidation,  in  all  cases  of  intussusception,  and 
in  all  cases  of  complete  mechanical  occlusion  of  the 
bowel,  it  is,  as  may  be  supposed,  absolutely  useless. 
In  cases,  however,  of  ileus  following  f?ecal  accumula- 
tion its  effects  have  often  been  very  remarkable  and 
very  decided,  an  evacuation  having  been  at  once  pro- 
duced in  severe  cases  after  repeated  enemata  and 
aperients  have  failed.  The  modus  operandi  is  as 
follows  :  The  mercury  does  not  act  by  its  weight,  but 
in  its  passage  along  the  intestine  it  becomes  very  finely 
divided,  and  on  reaching  the  stercoral  tumour  appears 
to  insinuate  itself  among  the  parts  of  the  fsecal  mass 
and  between  the  mass  and  the  bowel  wall,  and  so  to 
loosen  the  obstructing  matter  as  to  restore  the  normal 
passage.  This  mechanical  action  is  aided,  no  doubt,  by 
some  peristaltic  action  that  the  foreign  substance  may 
excite  in  the  intestinal  wall  as  it  passes  along.  In 
any  case  the  metal  appears  to  have  been  passed  in  a 
state  of  extremely  fine  division  and  not  in  a  coherent 
mass  as  when  swallowed.  In  cases  of  acute  and  of 
complete  mechanical  obstruction  the  quicksilver  has 
been  found  after  death  to  have  collected  into  a  single 
mass  above  the  obstruction,  the  separated  particles 
having  in  such  instances  cohered  again.  In  no  instance 
was  any  evidence  of  mercurial  poisoning  produced. 
In  several  of  the  cases  where  this  treatment  was 
adopted  the  vomiting  and  pain  were  immediately  sub- 
dued after  the  mercury  had  been  swallowed,  and  this 
result  is  supposed  to  be  due  to  the  interference  with 
the  movements  of  the  stomach  that  the  metal  may 
effect  by  its  mere  weight. 

The  dose  of  the  metal  administered  varies  from  50 
to  300  grammes,  and  in  most  cases  the  dose,  whether 
large  or  small,  has  been  many  times  repeated. 

jM.  Matigiion  rcpoi-ts  several  cases  of  relief  by  this 


432  Intestinal  Obstruction.    [Chap.  xxiv. 

treatment  in  obstruction  clue  to  faecal  accumnlation. 
In  these  exaniples  purges  and  enemata  had  failed,  the 
symptoms  had  become  very  grave,  and  in  some  the 
vomiting  had  become  feculent.  Metallic  mercury  was 
administered,  with  the  result,  that  the  vomiting  and 
pain  were  immediately  relieved,  and  the  bowels  were 
caused  to  act  after  a  few  hours.  In  each  of  the  cases 
quicksilver  was  passed  in  a  finely-divided  state  for 
some  three  or  four  days  after  the  first  evacuation,  and 
in  one  instance,  where  nearly  1,000  grammes  of  mer- 
cury had  been  given  in  several  doses,  the  metal  was 
noticed  in  the  motions  for  seventeen  days  after  the 
administration  of  the  last  dose. 

M.  Matignon's  cases  appear  so  clear  that  in  any 
case  of  faecal  accumulation  that  has  resisted  the  action 
of  aperients,  enemata,  massage,  electricity,  etc.,  the  use 
of  metallic  mercury  in  large  doses  would  appear  to  be 
worth  trying,  especially  as  the  mode  of  treatment 
appears  to  be  attended  by  no  especial  risk. 

Ice. — In  any  case,  and  especially  in  those  that  are 
of  an  acute  character,  the  patient  often  derives  much 
comfort  from  sucking  ice.  It  allays  the  thirst,  it 
moistens  the  parched  mouth,  and  it  certainly  in  many 
cases  moderates  the  sickness  a  little.  In  what  is 
known  as  GrissoUe's  method  the  use  of  cold  is  more 
extensively  adopted,  and  the  method  professes  to  be 
not  merely  palliative  but  also  curative.  In  this  pro- 
cedure the  patient  is  encouraged  to  take  as  much  ice 
by  the  mouth  as  possible ;  ice  is  at  the  same  time 
freely  applied  to  the  surface  of  the  abdomen  and 
enemata  of  iced  water  are  administered  at  frequent 
intervals.  The  precise  modus  operandi  of  Grissolle's 
method  in  cases  of  internal  strangulation  is  not  quite 
evident,  and  I  can  find  no  definite  account  of  any  in- 
stance where  cure  can  be  said  to  have  followed  this 
plan  of  treatment. 

Enemata  of  iced  weiter  are  apt  to  excite  consider- 


Chap.  XXIV.]    The  TreaTiMenT :  Electricity.      433 

able  peristaltic  movement,  and  may  therefore  in  many- 
cases  do  more  harm  than  good.  The  treatment  is  pro- 
bably more  adapted  for  the  relief  of  obstruction  due 
to  paresis  of  the  bowel  than  to  that  due  to  mechanical 
causes. 

Electricity  has  beeti  extensively  used  in  the  treat- 
ment of  intestinal  obstruction,  and  has  been  in  recent 
times  strongly  advised  by  eminent  authorities.  Many 
remarkable  cases  of  cure  have  been  ascribed  to  this 
method.  Some  of  these  cases  are  so  scantily  reported 
that  they  are  of  little  or  no  value,  since  they  furnish 
no  data  upon  which  to  base  any  independent  criticism 
of  the  diacjnosis. 

So  far  as  I  can  ascertain,  the  cases  of  cure  by  elec- 
tricity have  been  wholly,  or  for  the  most  part,  examples 
of  ileus  depending  upon  faecal  accumulation.  In  these 
cases,  in  which  a  paresis  of  the  gut  takes  so  conspi- 
cuous a  part,  the  mode  of  treatment  is  intelligible,  and 
may  be  expected,  h  priori,  to  be  of  benefit. 

Electricity  may  also  be  of  use  in  some  cases  of 
obstruction  due  to  foreign  substances  of  various  kinds. 
It  may  also  prove  of  service  in  some  instances  of  stric- 
ture or  of  stenosis  where  an  accumulation  has  taken 
place  above  the  narrowed  part,  which  the  unaided  con- 
tractions of  the  bowel  are  unable  to  relieve. 

It  is  very  difficult,  however,  to  understand  how 
electricity  can  have  the  least  curative  effect  in  acute 
strangulations  as  by  bands  or  through  slits  and  aper- 
tures. If  it  acts  by  increasing  peristaltic  movements, 
then  its  use  in  cases  of  this  kind  would  appear  to  be 
peculiarly  undesirable.  The  same  observations  ap})ly 
to  acute  or  subacute  intussusception  and  to  volvulus. 
In  these  affections  a  moderation  of  intestinal  move- 
ments is  a  condition  to  be  desired,  and  if  the  main 
effect  of  electricity  is  to  stimulate  those  movements, 
then  the  measure  is  calculated  to  do  harm  rather  than 
good.  I  have  met  with  accounts  of  a  large  number  of 
c  c — 12 


434  InTESTI.VAL    ObSTRUCTIO:^.      [Chap.  xxiv. 

cases  of  intestiiial  obstruction  treated  by  electricity, 
and  ill  all  such  of  these  cases  as  were  not  due  to  fecal 
accumulation  or  to  temporary  obstruction  in  cases  of 
incomplete  stenosis,  the  treatment  appears  to  liaA'e 
been  of  no  avail.  Some  examples  of  supposed  cure 
are,  I  think,  a  little  fanciful.  The  following  may  ser-se 
as  an  instance  :  "  Dr.  Clemens,  of  Frankfort,  states 
that  he  has  successfully  treated  invagination  by  first 
administering  one  or  two  tablesjioonfuls  of  metallic 
mercury,  which  settled  down  to  the  seat  of  the  invagi- 
nation. The  negative  electrode  was  applied  over  the 
supposed  seat  of  the  disease  and  the  positive  in  the 
rectum.  Voltaic  alternatives  were  used.'""^  In  con- 
nection with  this  case  I  might  point  out  that  post 
mortem  examinations  do  not  support  the  belief  that 
metallic  mercury,  when  taken  by  the  mouth,  will 
arrange  itself  above  an  invagmation,  as  here  described. 
Ill  many  cases  of  fsecal  accumulation  causing  ob- 
struction symptoms  electricity  has  given  relief,  and 
has  caused  a  motion  to  be  passed  after  aperients  and 
enemata  had  entirely  failed.  Of  its  power  in  affording 
relief  in  cases  of  stricture,  the  following  case  may  be 
taken  as  an  example  :  A  man,  aged  oQ,  had  had  occa- 
sional slight  attacks  of  intestinal  obstruction  from  time 
to  time  during  the  twelve  months  that  immediately 
preceded  his  death.  The  last  attack  had  lasted  already 
seventeen  days  when  the  patient  was  admitted  into 
hospital.  He  vomited  everything,  and  the  abdomen 
was  greatly  distended.  Aperients  and  enemata,  in- 
cluding enemata  of  seltzer  water,  had  no  effect.  On 
the  twenty-second  day  galvanism  was  applied,  and  had 
the  immediate  result  of  causing  the  patient  to  pass  a 
copious  motion.  He  was  much  relieved.  The  symp- 
toms, however,  returned,  inguinal  colotomy  was  per- 
formed on  the  right  side,  and  the  patient  died  on  the 

*  Medical  and  Bwrgical  Electricity,  by  Beai-d  and  Rockwell, 
page  484.     New  York,  iS71. 


Chap.  XXI v.]    The  Treatment :  Electricity.      435 

following  day.     The  obstruction  was  due  to  an  epitlie- 
liomatous  stricture  of  the  sigmoid  flexure.* 

There  have  been  a  fcAv  cases  reported  of  internnl 
strangulation  where  electricity  gave  some  slight  tem- 
porary relief  without,  however,  affecting  the  actual 
obstruction.  Thus,  M.  Terrier  records  the  case  of  a 
woman,  aged  twenty-one,  who  was  suffering  from 
strangulation  of  a  portion  of  the  intestine  beneath  a 
band  connected  Avith  the  Ijroad  ligament.  On  the- 
third  day  electricity  was  used,  and  is  said  to  have  re- 
lieved the  pain  and  to  have  moderated  the  vomiting. 
The  symptoms,  however,  persisted  and  laparotomy  was 
performed  on  the  fourth  day  with  success,  f 

There  are  several  methods  of  applying  electricity  in 
these  cases  of  abdominal  obstruction.  1.  Both  elec- 
trodes are  placed  upon  the  abdomen  =  abdominal 
method.  2.  One  pole  (the  negative)  is  placed  upon  the 
abdomen,  the  other  just  within  the  anus  —  ano-abdo- 
minal.  3.  One  electrode  (the  negative)  is  placed  over 
the  dorsal  spine  while  the  other  is  introduced  some 
distance  up  the  rectum  =  recto-spinal.  4.  The  nega- 
tive pole  touches  the  abdomen  while  the  positive  is 
applied  within  the  rectum  —  recto-abdominal.  In  the 
two  last-mentioned  methods  the  electrode  is  made  of 
a  copper  ball  mounted  on  an  isolating  handle,  so  that 
the  current  may  pass  to  the  gut  direct  without  involving 
the  anus  and  lower  part  of  the  rectum.  In  all  cases 
and  in  all  forms  the  faradic  current  is  advised.  The 
method  most  particularly  advocated  by  those  who  have 
written  upon  the  subject  is  the  recto-abdominal.  The 
effects  that  have  been  demanded  for  this  form  of  elec- 
tric application  are  the  following  :  The  abdominal 
muscles  contract ;  the  intestines  contract  and  propel 
forwards  their  contents ;  flatus  disappears  from  the 
intestine  without  being  either  expelled  from  the  mouth 

*  Archives  Gen.  cle  Med. ,  1879.  vol.  ii. ,  page  207  ;  M.  Diiplay. 
t  Bull,  et  Mem.  de  la  Roc.  de  Chir.  de  Paris,  1879,  page  5(34. 


43^  Intestinal  Obstruction,     tchap.  xxiv. 

or  the  anus  ;  and  the  symptoms  of  collapse  are  relieved 
if  they  exist.  * 

Massage. — Massage  of  the  abdomen  has  been 
somewhat  extensively  tried  in  many  forms  of  intes- 
tinal obstruction,  especially  in  France.  Its  action  is 
very  vague  and  its  general  effects  uncertain  and  un- 
satisfactory. It  has  often  been  used  with  much  suc- 
cess in  constipation  and  in  obstruction  due  to  faecal 
masses,  to  gall  stones,  and  to  foreign  substances.  In 
these  cases  the  manipulation  of  the  abdomen  probably 
not  only  excites  peristaltic  movement  but  also  directly 
dislodges  the  obstructing  matter.  As  an  illustration 
may  be  cited  a  case  reported  by  Martin.  The  patient, 
a  woman  aged  seventy-eight,  was  suflfering  from  symp- 
toms of  severe  obstruction  due  to  the  impaction, 
probably  in  the  terminal  part  of  the  ileum,  of  a  large 
gall-stone.  Aperients  had  had  no  effect  and  the 
vomiting  had  become  stercoraceous.  A  tumour  could 
be  detected  in  the  right  iliac  fossa.  On  the  sixth  day 
massage  was  employed  ;  relief  followed,  and  on  the 
next  day  a  large  gall-stone  with  ten  smaller  stones 
were  evacuated.! 

Massage  has  been  frequently  used  in  cases  of  intus- 
susception. I  can,  however,  find  no  case  where  cure 
can  be  said  to  have  followed  this  treatment  alone.  In 
the  cases  of  reputed  cure  the  massage  was  usually  sub- 
sequent to,  or  coincident  with,  the  administration  of 
copious  cnemata,J  and  the  morbid  anatomy  of  invagi- 
nation would  lead  us  to  suppose  that  the  injection 
would  have  more  effect  than  the  manipuhition,  I  ima- 
gine that  massage  in  these  cases  would  tend  to  excite 
an  undesirable  amount  of  peristaltic  action,  although 
it  is  quite  reasonable  to  suppose  that  it  might  prove  of 

*  See  L'Occlusion  Intcstinale,  by  A.  Bulteau.  Thfese  de  Paris, 
1878,  No.  427. 

t  Bull,  dela  Soc.  Anat.  de  Paris,  1875,  page  195. 

X  See  cane  by  Dr.  Gillette,  JVew  York  Med.  Joiwn. ,  1882,  page 
261. 


Chap.  XXIV.]   The  Treatment :  Massage,  437 

service  if  applied  when  the  patient  was  under  the  in- 
fluence of  an  anaesthetic  or  a  narcotic. 

In  other  cases  of  acute  obstruction  I  imagine 
that  this  mode  of  treatment  would  probably  do  more 
harm  than  good.  It  could  never  be  applied  with  any 
scientific  precision. 

In  several  of  the  reputed  examples  of  cure  by  mas- 
saii'e  other  modes  of  treatment  had  been  adopted  to 
which  some  share  in  the  cure  may  possibly  be  ascribed. 
This  is  well  illustrated  in  a  remarkable  case  reported 
by  M.  Bitterlin.  The  patient,  a  man  aged  fifty-six, 
was  seized  with  symptoms  of  acute  intestinal  ob- 
struction. The  obstruction  lasted  ten  days  and  the 
symptoms  Avere  very  severe.  During  these  ten  days 
the  following  therapeutic  measures  were  adopted  for 
the  relief  of  the  unfortunate  patient.  Morphia  was 
administered,  followed  by  large  doses  of  castor-oil, 
and  subsequently  by  large  doses  of  croton-oil.  Ene- 
mata  of  water,  of  senna,  of  sulphate  of  magnesia,  and 
of  tobacco  were  injected  at  different  times.  Poultices 
were  first  of  all  applied  to  the  abdomen,  and  these 
were  in  time  followed  by  frictions  with  belladonna. 
Electricity  was  used.  All  these  means  were  without 
effect.  At  last  massage  was  tried,  an  almost  immediate 
relief  followed,  and  the  patient  recovered  in  spite  of 
treatment."^ 

The  various  mechanical  methods  adopted  for  the 
relief  of  constipation  in  what  is  usually  known  as  the 
"  Swedish  movement  cure,"  seem  to  have  met  with  a 
very  encouraging  degree  of  success.  The  machines 
employed  are  of  different  descriptions.  In  one  the 
patient  lies  upon  the  abdomen  over  an  opening,  and  in 
this  opening  rollers  move  which  exercise  a  kneading 
action  over  the  whole  of  the  belly.  In  another  machine 
two  rollers  are  caused  to  rotate  along  the  course  of 
the  large  intestine. 

*  L'UniouMedicale,  1882,  page  433. 


438  Intestinal  Obstruction.    [Chap.  xxiv. 

In  other  machines,  passive  rotation  of  the  lower 
part  of  the  trunk  and  passive  oscillation  of  the  pelvis 
are  brought  about,  with  the  effect,  it  is  said,  of 
stimulating  peristaltic  movements  in  the  intestine. 
In  still  other  machines  the  patient  sits  upon  a  saddle, 
and  is  subjected  to  movements  which  imitate  more  or 
less  the  movements  incident  to  horse  exercise."^ 

EiieiiiatR.. — Copious  enemata  of  water  are  of  con- 
siderable service  in  cases  of  intestinal  obstruction. 
Beyond  the  fact  that  an  enema  may  excite  peristaltic 
action  in  a  large  segment  of  the  small  intestine  they 
are  of  use  only  when  the  obstruction  involves,  in 
whole  or  in  part,  the  large  intestine.  In  the  cadaver, 
water  forcibly  injected  at  the  anus  can  occa- 
sionally be  made  to  pass  through  the  ileo-csecal 
valve.  There  is  often  no  difficulty  in  this.  In  the 
living  subject,  however,  there  is  every  reason  to 
believe  that  the  valve  does  not  yield,  and  that  the 
direct  action  of  the  enema  ceases  abruptly  at  the 
ileo-c£ecal  junction. 

There  are  morbid  circumstances  in  the  living 
subject,  how^ever,  under  which  it  may  be  possible  for 
the  valve  to  become  insufficient.  Thus  there  are  good 
reasons  for  believing  that  when  the  patient  is  under 
the  influence  of  an  anaesthetic  water  may  sometimes 
be  made  to  pass  beyond  the  colon  into  the  ileum.  In 
cases,  too,  of  obstruction  associated  with  paral3^sis  of 
the  ileo-c?ecal  segment  of  the  bowel  the  valve  may 
prove  to  be  insufficient,  esjiecially  when  the  activity 
of  reflex  action  has  been  moderated  by  opium.  Mere 
distension  of  the  colon  would  appear  to  increase  rather 
than  to  diminish  the  competency  of  this  internal  anus. 

There  are  ditl'erent  methods  of  administering 
enemata.     In  the  great  majority  of  cases  th'e  ordinary 

*  Diagrams  of  most  of  these  machines  are  given  in  Mecha- 
nical Exercise  a  Means  of  Cure,  the  work  being  a  descrij^tion  of  the 
Zander  Institute  in  London,  lb83. 


Chap.  XXIV.]    The  Treatment  :  E-nemata.  439 

enema-pump  or  syringe  is  all  that  is  required.  A 
somewhat  better  instrument  than  this,  even  for 
ordinary  purposes,  is  the  syphon  apparatus.  This 
consists  essentially  of  a  large  funnel,  to  which  is 
attached  a  long  indiarubber  pipe  ending  in  a  more 
solid  tube  for  introduction  into  the  rectum.  Between 
the  two  tubes  is  a  tap.  In  the  administration  of 
enemata  by  this  means  the  patient  should  be  placed 
in  such  a  position  as  to  reduce  the  abdominal  pressure 
as  much  as  possible.  The  knee-and-head,  knee  and- 
elbow,  and  lateral  abdominal  positions  are  the  best. 
The  water  enters  by  gravitation,  and  the  pressure  of 
the  entering  column  can  be  increased  or  diminished 
by  raising  or  lowering  the  funnel  containing  the 
injection  material.  This  method  has  great  advantages 
over  the  ordinary  syringe.  The  fluid  is  introduced  in 
a  constant  and  easily  regulated  stream,  and  not  in 
intermittent  gushes.  The  bowel  being  more  tolerant 
of  the  former  method^  it  follows  that  much  larger 
quantities  of  fluid  can  be  introduced  by  this  means 
than  by  the  common  syringe.  The  jDi'essure,  more- 
over, that  is  exercised  upon  the  walls  of  the  bowel  is 
uniform  and  can  be  slowly  and  regularly  increased. 

Enemata  as  administered  by  one  or  other  of  these 
methods  are  of  infinite  service  in  many  cases  of 
obstruction.  By  their  means  the  large  intestine  may 
be  cleared.  In  cases  of  obstruction  due  to  f^cal 
accumulation  enemata  constitute  the  principal  active 
treatment.  By  the  use  of  frequent  and  copious 
injections  a  distended  colon  may  be  gradually  emptied 
of  its  contents  from  the  rectum  to  the  caecum.  When 
used  for  the  purpose  of  evacuating  the  colon  different 
fluids  have  been  recommended.  In  most  cases  warm 
water  is  all  that  is  required.  When  a  more  stimu- 
lating injection  is  needed  a  little  turpentine  is  added. 
In  some  instances  an  alkali  is  mixed  with  the  water, 
under   the   impression  that  bv    such   admixture  the 


44 o  Intestinal  Obstruction.     [Chap.  xxiv. 

impacted  fseces  are  more  readily  acted  upon.  The 
alkali  usually  is  introduced  by  uiixin*.;;  soap  with  the 
water.  With  a  like  object  in  view  enemata  of  oil  or 
of  mixtures  containing  oil  have  been  made  use  of. 

In  other  instances  some  aperient  has  been  used 
as  the  enema-material,  and  solutions  of  senna  or  of 
sulphate  of  magnesia  have  been  thrown  up  the  bowel. 
Here  the  ordinary  action  of  the  injection  is  supple- 
mented by  the  absorption  of  purgative  drugs. 

Enemata  are  also  of  considerable  use  in  relieving 
obstructions  due  to  accumulation  above  a  stricture  or 
stenosis  in  the  colon.  In  many  cases  it  has  been 
found  that  water  can  be  made  to  enter  the  narrowed 
gut  from  below,  while  the  part  remains  impervious  to 
water  introduced  from  above.  A  stricture  of  the 
colon  may  long  be  prevented  from  causing  a  complete 
and  final  obstruction  by  the  frequent  and  patient  use 
of  enemata.  Injections  have  also  been  of  much 
service  in  relieving  accumulations  that  have  taken 
place  above  chronic  invaginations  occupying  the  large 
intestine. 

In  cases  of  volvulus  of  the  colon  enemata  would 
appear  to  be  of  no  use  as  curative  measures,  and  the 
same  observation  apj^lies  in  a  still  more  marked 
degree  to  examples  of  acute  intestinal  strangula- 
tion. 

Enemata,  however,  can  be  used  in  obstruction 
cases  for  other  purposes  than  the  simple  evacuation  of 
the  colon.  They  have  proved  of  considerable  service 
in  reducting  intussusceptions  that  occupy  the  large 
intestine,  i.e.  such  as  are  colic,  ileo-colic,  or  ileo- 
csecal.  To  effect  this  reduction  large  quantities  of 
fluid,  and  in  such  cases  only  warm  water  is  used,  are 
injected  with  considerable  force  ("forcible  enemata," 
"  monster  clysters  ").  The  ordinary  syringe  or  pump 
may  be  used  for  this  purpose,  the  return  of  the  water 
being  prevented  by  an  assistant  who  presses  the  sides 


Chap.  XXIV.]    The  Treatment:  Enemata,  AcAc'i- 

of  the  buttocks  and  the  margins  of  the  anus  as  close 
as  possible  against  th(}  tube.  This  apparatus,  how- 
ever, is  ol)jectionable.  The  fluid  is  introduced  spas- 
modically, and  it  is  difficult  to  estimate  what  amount 
of  force  is  being  used. 

A.  far  better  method  is  by  the  syphon  apparatus. 
If  the  tube  of  this  enema  be  made  very  long,  and  the 
funnel  be  placed  at  a  considerable  height,  the  fluid  can 
be  caused  to  enter  the  rectum,  not  only  with  great 
force,  but  also  with  a  uniform  and  easily  regulated 
pressure.  In  both  forms  of  enema  there  is  much 
difficulty  in  retaining  the  injected  fluid.  This  diffi- 
culty can,  however,  be  well  met  by  adapting  to  the 
rectal  tube  of  the  syphon-apparatus  the  very 
ingenious  elastic  ring  and  handle  devised  by  Mr. 
Lund  for  his  air- inflation  instrument  (Fig.  57). 

In  many  cases  the  injection  has  been  administered 
while  the  patient  was  partly  inverted.  This  position 
has,  however,  I  think,  no  peculiar  advantage.  If  it 
facilitates  the  passage  of  fluid  along  the  descending 
colon  it  must  at  the  same  time  hinder  its  passage 
along  the  ascending  colon.  The  best  positions  for  the 
purpose  are  those  already  referred  to,  viz.  the  head- 
and-.'knee,  knee -and -elbow,  and  lateral  abdominal 
positions.  I  think  it  extremely  important  that  the 
injected  fluid  should  be  forcibly  retained  for  a  con- 
siderahle  time.  Its  reducing  action  upon  the  in- 
vaginated  bowel  must  be  slow  and  gradual,  and  the 
bowel  should  therefore  be  kept  distended  for  at  least 
fifteen  minutes.  Dr.  Eastes  has  recorded  an  in- 
teresting case  where  an  intussusception  was  quietly 
reduced  by  means  of  a  forcible  enema,  Avhich  was  not 
allowed  to  escape  for  a  quarter  of  an  hour.  "^  Many 
examples  may  be  given  of  the  ready  reduction  of  an 
invagination  by  means  of  enemata  only,  both  with 
and  without  the  assistance  of  chloroform.  This 
*  Lancet,  vol.  ii.,  1869,  page  669. 


442  Intestinal   Obstruction,     [Chap.  xxiv. 

subject  will  be  further  considered  in  dealing  with  the 
treatment  of  invagination. 

Enemata  of  a  mixture  of  tobacco-juice  and  water, 
and  even  insufflations  of  tobacco-smoke,  were  at  one 
time  in  great  repute  among  the  therapeutic  measures 
available  for  intestinal  obstruction.  It  was  supposed 
that  the  tobacco  subdued  spasm  and  relaxed  the 
muscular  contraction  of  the  bowel.  The  measure  was 
used  at  a  time  when  spasmodic  stricture  of  the 
intestine  was  considered  to  be  a  fairly  common 
affection.  Experience  has  shown  this  treatment  to 
be  not  only  useless  but  also  to  be  obnoxious  in  many 
ways.  If  an  anti-spasmodic  be  required  it  can  be 
administered  in  a  more  satisfactory  manner  than  by 
introducing  tobacco-juice  into  the  rectum. 

Insufflation. — The  forcible  injection  of  air  into 
the  colon  has  been  used  to  excite  peristaltic  movements 
in  cases  of  chronic  constipation  and  obstruction  by 
stercoral  masses.  It  is,  however^  not  so  efficacious  as 
an  injection  of  fluid,  and  has  no  advantages  over  that 
method  of  treatment.  Insufflation  has,  however,  been 
extensively  used  in  cases  of  intussusception  for  the 
purpose  of  reducing  the  invagination.  Air-inflation 
acts  in  precisely  the  same  way  as  the  forcible  enema, 
and  it  might  be  said  at  once  that,  as  a  means  of 
reducing  an  intussusception,  it  is  inferior  to  the 
injection.  Before  it  can  be  used  the  bowel  must  be 
emptied  by  enemata,  and  there  are  no  cogent  reasons 
why  in  the  further  treatment  these  enemata  should  be 
replaced  by  insufflation.  Indeed,  instances  can  be 
given  where  insufflation  has  failed  but  where  in- 
jections have  been  successful  in  reducing  an  invagi- 
nation."^ There  are  at  the  same  time  not  a  few 
examples  of  the  cure  of  intussusception  by  air- 
inflation  only. 

The  procedure  is  usually  carried  out  by  means  of  a 

*  Sec  case  by  ]\Ir.  "Waren  Tay  :  Lancet,  vol.  i.,  1S7G.  page  13. 


Chap,  xxiv.j  Ti IF.  Treatment  :  Insufflation.     443 

common  bellows,  to  which  an  indiarubber  pipe  and  a 
rectal  tube  have  Ijeen  attached.* 

By  far  the  best  instrument,  however,  for  the 
purpose  is  that  designed  by  Mr.  Lund  of  Manchester 
(Fig.  57).  It  consists  of  an  air-syringe  and  a  rectum- 
tube.  "The  merit  of  the  invention,"  writes  Mr. 
Lund,  "  consists  in  a  particular  mode  of  securing  an 
air-tight  contact  around  the  margin  of  the  anus,  l)y 
the  use  of  a  hollow  elastic  ring  e  placed  over  the 
tube,  which  is  compressed  and  flattened  against  the 


Fig.  57.— Lnnd's  Inflator. 
A,airsyrin£?o  ;  ti,  Blionlderonond  of  liandlec  ;  i),  point  wbero  air  enters  tliorcrtnm 
tube ;  E,  liollow  clastic  ring ;  v,  a  long  narrow  rectum  tube  for  cases  of  rectal 
stricture,  etc. 

shoulder  b  on  the  handle  c,  when  firmly  pressed 
against  the  part  by  an  assistant.  This  method  of 
preventing  the  return  of  the  air  as  it  is  pumped  into 
the  bowel  is  more  effective  than  anything  of  the 
nature  of  a  plug  or  tamj)on  introduced  within  the 
rectum,  even  if  it  be  carefully  adjusted  to  the  size  of 
that  cavity,  for  the  air  so  injected  is  sure  to  escape 
by  the  side  of  the  plug,  the  anus  and  rectum  being 
immensely  expansible.  .  .  .  With  the  apparatus, 
when  the  hollow  ring  is  compressed,  the  central  hole 

*  yStec  art.  by  Dr.  Trastour  ;  Bull,  g^n  de  Thf'rap.,  1874,  page  107. 


444  Intestinal  Obstruction.    [Chap.  xxiv. 

in  it  is  diminished  in  size,  tlie  skin  around  the  anus, 
to  which  the  indiarubber  clings  Avith  gi'eat  tenacity, 
is  drawn  inwards  towards  this  centre,  and  the  tight- 
ness of  the  air-joint  thus  formed  can  be  well  sus- 
tained."* 

Mr.  Lund's  instrument  was  more  especially  de- 
vised for  distending  the  colon  in  lumbar  colotomy. 

Eiieinata  of  carbonic  acid.— Distension  of  the 
colon  by  carbonic  acid  may  be  effected  in  two  ways. 
In  the  first  method  the  gas  is  derived  from  an  ordinary 
"  syphon  "  of  seltzer  or  soda-Avater.  A  tube  is  passed 
up  the  rectum  as  far  as  it  will  go.  To  the  end  of 
this  tube  an  indiarubber  pipe  is  attached  which  is 
connected  by  its  other  extremity  with  the  nozzle  of  a 
"  syphon."  The  syphon  should  be  of  large  size, 
capable  of  holding  a  quart.  An  assistant  presses  the 
margins  of  the  anus  against  the  tube,  and,  everything 
being  in  readiness,  the  button  of  the  syphon  is 
pressed  and  its  contents  pass  into  the  rectum,  f 

In  the  second  method  the  distension  is  effected  by 
mtroducing  first  a  solution  of  bicarbonate  of  soda  and 
then  a  solution  of  tartaric  acid  into  the  rectum,  so 
that  the  gas  is  generated  within  the  bowel.  A  long 
rectal  tube  is  used,  which  is  connected  by  an  india- 
rubber  pipe  with  a  glass  funnel.  The  two  drugs  are 
introduced  in  solution,  one  being  poured  in  after  the 
other  has  had  full  time  to  find  its  way  into  the 
intestine.  When  the  two  solutions  have  been  in- 
troduced a  certain  quantity  of  Avater  is  rapidly 
poured  in.  The  escape  of  the  gas  is  prevented  by 
forcibly  pressing  the  buttocks  together  about  the 
tube,  escape  also  being  proA^ented  along  the  tube 
itself.  Ziemssen,  who  has  wi'itten  in  high  praise  of 
this  mode  of  distending  the  boAvel,  says  that  for 
complete  dilatation  of  the  colon  in  an  adult  tAventy 

*  Lancet,  vol.  i. ,  1S8.3,  page  588. 

t  See  Bull.  gen.  de  Th^rap.,  1877,  page  223 ;  Dr.  Gamier. 


Chap. xxv.i    The  Treatment :  Puncture.  445 

grammes  of  bicarbonate  of  soda  are  required  and 
fifteen  grammes  of  tartaric  acid.  He  recommends 
that  the  solutions  should  be  introduced  grcxdually,  or 
at  least  in  three  parts.  He  points  out  that  the  ileo- 
csecal  valve  remains  firm  even  against  strong  pressure, 
but  states  that  under  the  influence  of  the  carbonic 
acid  it  may  yield  a  little  so  as  to  allow  gas  to  reach 
the  small  intestine."^ 

Ziemssen  asserts  that  this  form  of  enema  is  of 
great  value  in  reducing  intussusceptions,  and  that  it 
is  superior  to  the  ordinary  injection  of  water.  He 
regards  it  also  as  a  very  efficient  aperient,  and  states 
that  it  induces  intense  peristaltic  action.  Previous 
authors  have  stated  that  carbonic  acid  acts  as  a 
sedative  to  tlie  intestine,  and  that  injections  of  it  may 
be  used  to  allay  the  pains  of  colic.  Ziemssen  believes 
this  form  of  enema  to  be  of  diagnostic  value  as  a 
means  of  ascertaining  the  dilatability  of  the  colon, 
and  also  as  demonstrating  possibly  the  position  of  an 
obstruction  in  the  bowel. 


CHAPTER  XXV. 

THE  TREATMENT — OPERATIVE  MEASURES. 

Puncture  of  the  toowel  with  a  liuc 
trochar. — In  this  procedure  an  aspirator  needle  or 
a  fine  trochar  is  thrust  into  the  abdomen  over  some 
prominent  coil  of  intestine,  and  relief  is  sought  to  be 
afforded  by  the  escape  of  matters,  flvdd  and  gaseous, 
from  the  distended  bowel. 

It  cannot  be  said  that  this  is  a  very  scientific 
operation,  nor  one  that  can  be  adopted  with  any  preci- 
sion or  carried  out  witH  any  very  definite  purpose. 

*  Archiv  fur  Klin.  Med.,  bd.  ;iS,  3  and  4. 


44^  Intestinal  Obstruction.      [Chap.  xxv. 

It  must  be  regarded  as  a  palliative  rather  than  as 
a  curative  measure. 

In  many  forms  of  obstruction  great  distress  is 
occasioned  by  the  distension  of  the  abdomen,  much 
dyspnoea  may  be  produced,  the  pain  increased,  and  the 
vomiting  rendered  more  troublesome.  Indeed,  in 
some  cases  of  rapid  and  extreme  distension,  such  as 
may  be  met  with  in  volvulus  of  the  sigmoid  flexure, 
the  meteoristic  bowels  may  so  press  upon  the  dia- 
phragm and  the  thoracic  viscera  as  to  cause  more  or 
less  sudden  death.  In  cases  of  distension  puncture 
usually  affords  very  considerable  relief.  The  punctures 
may  be  repeated  many  times  or  made  in  many  parts 
of  the  abdomen  at  once,  and  the  amount  of  flatus  and 
occasionally  of  fluid  matter  that  may  be  in  this  way 
removed  is  often  considerable.  The  procedure,  more- 
over, has  been  advocated  as  a  valuable  measure  in 
diagnosis.  By  its  means  distended  coils  may  be 
emptied  and  a  tumour  or  other  condition  be  revealed 
that  had  been  hitherto  hidden  from  view. 

It  has  been  recommended  also  as  a  preliminary  to 
laparotcray  by  surgeons  who,  in  performing  this 
operation,  have  been  troubled  by  the  premature  escape 
of  the  distended  coils. 

With  regard  to  puncture  as  a  curative  measure 
one  must  note  that  several  cases  of  obstruction  have 
been  recorded  which  have  been  apparently  cured  by 
this  procedure  and  by  it  alone.  In  illustration,  I 
might  take  an  example  of  an  acute  case  and  then  an 
example  of  a  chronic  one. 

M.  Le  Fort  mentions  the  case  of  a  man  with 
symptoms  of  acute  internal  strangulation  upon  whom 
he  was  about  to  perform  laparotomy.  Before,  how- 
ever, proceeding  to  this  measure  he  punctured  the  ab- 
domen with  a  capillary  trochar  once  in  the  right 
hypochondrium  and  twice  in  the  site  of  the  transverse 
colon.     Some   flatus   and  fluid  f<eces  escaped.       The 


Chap.  XXV.]  The  Treatment :  Puncture.  447 

next  day  the  man  passed  a  copious  motion,  and  a  rapid 
and  complete  recovery  followed.* 

Mr.  AVorthino-ton  details  a  case  of  chronic  consti- 
pation  ending  in  an  acute  attack  in  the  person  of  a 
man  aged  twenty-eight.  The  symptoms  were  severe, 
there  was  great  meteorism  and  stercoraceous  vomitino-. 
On  the  seventh  day  a  fine  trochar  was  introduced  and 
retained  thirty  minutes.  Much  fluid  and  flatus  escaped. 
Next  day  a  stool  was  passed,  and  the  patient  made  a 
good  recovery.! 

Without  discussing  the  probable  nature  of  these  or 
of  like  cases  "we  may  proceed  to  consider  what  form  or 
forms  of  obstruction  are  likely  to  be  benefited  by  this 
m.ode  of  treatment. 

Puncture  of  the  involved  coil  has  been  suggested 
as  a  means  of  cure  in  volvulus  of  the  colon.  It  is  true 
that  at  autopsies  it  has  often  been  found  impossible  to 
reduce  a  volvulus  until  it  had  been  emptied  by  a 
trochar,  but  I  am  not  aware  that  the  emptying  alone 
has  been  suflicient  in  any  case  to  effect  reduction. 
Indeed,  I  can  refer  to  cases  both  of  volvulus  of  the 
sigmoid  flexure  |  and  of  the  caecum  §  where  capillary 
puncture  was  resorted  to  during  life  without  any 
enduring  benefit. 

Evacuation  of  the  contents  of  the  upper  segment 
of  the  bowel  may  completely  relieve  obstruction  due 
to  kinking,  or  to  acute  bending  of  the  intestine.  It 
may  also  allow  of  the  spontaneous  reduction  of  a  coil 
that  is  lightly  held  under  a  band  or  is  involved,  with- 
out severe  strangulation,  in  some  abnormal  aperture. 
It  may  afford  marked  and  long-continued  relief  in 
cases  of  temporary  complete  obstruction  depending 
upon  stricture,  upon  any  form  of  stenosis,  upon  faecal 

*  Biill.  et  M€in.  de  la  Soc.  de  Cliii-.  de  Paris,  1879,  page  641. 
i-  Bi'it.  Med.  Journ.,  vol.  ii.,  1882,  page  167. 
:J:Coiitrib.  a  TEtude  de  I'Occlus.   intes.,  by  J.  M.  Le  Moyne. 
These  de  Paris,  1878. 

§  Dr.  Hilton  Fagge  ;  Guy's  Hosp.  ReiDorts,  vol.  xiv. ,  page  27:?, 


44^  Intestinal  Obstruction.      [Chap.  XjCV. 

accumulation,  or  upon  the  impaction  of  a  foreign  sub- 
stance. It  may  give  decided  relief  in  cases  of  chronic 
"stoppage"  Avhere  symptoms  of  acute  obstruction 
have  developed  suddenly  as  a  result  of  changes  follow- 
ing upon  great  distension  of  the  bowel. 

But  even  should  a  correct  diagnosis  be  made  in 
such  cases  as  the  above,  it  must  still  remain  an  open 
question  whether  relief  should  be  sought  by  this 
means.  It  is  true  that  in  most  instances  the  little 
operation  is  associated  with  no  evil  results,  even  if  it 
does  not  give  relief,  but  its  application  is  attended  by 
great  uncertainty.  The  proper  coil  of  intestine  may 
be  hit,  or  it  may  not  be.  In  any  case  it  is  probable 
that  the  trochar  would  enter  a  distended  loop,  but  it 
may  be  one  so  far  away  from  the  seat  of  obstruction 
that  the  evacuation  of  its  contents  is  attended  by  no 
real  benefit.  In  the  great  majority  of  cases,  there- 
fore, the  puncture  must  be  made  purely  at  hazard  and 
blindly,  and  its  chances  of  hitting  the  exact  spot  are 
about  those  of  the  arrow  from  the  bow  "  drawn  at  a 
venture."  In  not  a  few  cases  the  trochar  has  entered 
the  bowel  below  the  obstruction.  Thus,  in  one  ex- 
ample of  stricture  involving  the  terminal  part  of  the 
ileum  a  trochar  Avas  thrust  into  the  transverse  colon 
and  retained  there  during  the  night.  About  forty 
ounces  of  fluid  faeces  escaped,  but  no  relief  was 
afforded.* 

Even  when  the  trochar  strikes  the  proper  segment 
of  the  intestine  an  amount  of  distress  may  be  occa- 
sioned by  the  instrument  which  is  not  counterbalanced 
by  any  relief  following  the  evacuation  of  intestinal 
contents.  Thus^  in  a  case  of  chronic  obstruction  due 
to  a  lesion  involving  the  lower  ileum  a  fine  trochar 
was  introduced.  It  was  proposed  to  retain  it  for  some 
time.  The  instrument  was,  however,  carried  round 
and  round  by  the  peristaltic  action  of  the  bowel,  and 
*  Lancd,  vol.  i. ,  1883,  page  42 :   by  Dr.  Wm.  Piatt. 


Chap. XXV.]  The  Treatment :  Puncture,  449 

so  much  pain  was  occasioned  that  it  had  to  be  removed 
at  the  end  of  two  hours."^ 

Before  conchiding  this  subject  it  must  be  pointed 
out  that  puncture  of  the  intestine  is  not  quite  so  en- 
tirely harmless  a  procedure  as  is  sometimes  supposed. 
The  punctured  gut  is  much  distended  and  often  in  a 
state  of  temporary  paralysis ;  so  that  after  the  trochar 
is  withdrawn  the  little  hole  is  not  eihciently  closed, 
and  faecal  extravasation  may  follow.  The  more 
minute  the  trochar  the  smaller  the  hole  to  be  closed, 
but  at  the  same  time  the  amount  of  matter  evacuated 
by  very  slight  instruments  is  so  trifling  that  the  opera- 
tion has  no  raison  d'etre.  Then,  again,  the  puncture 
may  involve  a  friable  piece  of  gut  on  the  point  of 
gangrene,  and  faecal  extravasation  may  again  ensue. 
Mr,  Hulke,  in  performing  a  laparotomy,  punctured 
the  distended  intestine.  The  gut  so  treated  was  in  a 
precarious  condition.  The  hole  did  not  close,  attempts 
to  close  it  made  it  larger,  until  at  last  it  had  to  be 
converted  into  an  artificial  anus.f 

One  other  point  may  be  noticed.  I  have  met  with 
several  instances  where  perforation  of  the  bowel  that 
had  been  previously  threatening  took  place  imme- 
diately after  the  relief  of  a  distended  coil.  In  one  of 
these  cases  I  had  performed  left  lumbar  colotomy  for 
the  relief  of  a  stricture  of  the  sigmoid  flexure.  Little 
faeces  escaped  at  the  time  of  the  operation.  During 
the  night  there  was  a  copious  evacuation  through  the 
wound.  Shortly  afterwards  the  patient  developed 
evidences  of  perforative  peritonitis,  of  which  she  died. 
The  autopsy  showed  extensive  ulceration  of  the  caecum 
and  a  perforation  at  the  base  of  one  of  these  ulcers. 
Dr.  Bristowe  describes  a  case  of  stricture  of  the  sigmoid 

*  Dr.  Hilton  Fagge,  loc.  cit, 

t  Medical  Times  and  Gazette,  vol.  ii.,  1872,  page  482.  See  also 
Paper  by  Prof.  G.  Macleod ;  Glasgoio  Med.  Journ. ,  March,  1884, 
page  167' 

DD— 12 


450  Intestinal  Obstruction.      [Chap.  xxv. 

flexure  associated  with  great  distension  of  the  abdo- 
men, to  relieve  which  he  used  a  trochar.  In  thirty 
minutes  acute  peritonitis  set  in,  of  which  the  patient 
died  next  day.  The  autopsy  revealed  the  trochar 
punctures  perfectly  closed.  Fsecal  exti*avasation  had 
taken  place  through  a  perforation  in  the  lower  ileum, 
the  aperture  being  at  the  base  of  an  extensive  nicer. "^ 
In  these  cases,  and  I  could  allude  to  others,  it  would 
appear  that  some  disturbance  in  the  amount  of  pres- 
sure brought  to  bear  ujion  various  segments  of  the 
bowel  follows  from  the  sudden  relief  of  distension,  and 
a  potential  perforation  is  thereby  rendered  an  actual 
one. 

In  favour  of  the  liarmlessness  of  puncture  of  the 
abdomen  the  case  reported  by  Dr.  Blake  may  be  again 
alluded  to.  In  this  case,  during  a  constipation  that 
was  absolute  for  eighteen  weeks,  the  abdomen  was 
punctured  no  less  than  150  times,  about  half  a  pint  of 
intestinal  contents,  in  addition  to  some  flatus,  being- 
drawn  off  each  time. 

Eiitei'ocentcsis. — This  operation  was  devised 
by  Dr.  Larguier  des  Bancels.f  It  merely  consists  in 
puncturing  the  intestine  with  a  large  trochar,  the 
instrument  to  be  retained  as  long  as  necessary. 

Dr.  Larguier  uses  a  tro.'*har  with  a  diameter  of 
five  to  six  mm.,  and  leave.s  it  in  the  intestine  at 
least  two  or  three  days.  In  one  case  the  procedure 
led  to  a  fjecal  fistula,  which,  however,  closed  in  time. 
Dr.  Larguier  gives  an  account  of  five  cases  in  which 
this  puncture  was  adopted.  Three  recovered,  one  was 
relieved,  and  one  died.  The  cases  were  of  a  chronic 
character,  and  in  one  instance  of  obstruction  due  to 
ftecal  accumulation  the  relief  w^as  certainly  marked 
and    immediate.       The    operation    can^    however,   in 

*  Path.  Soc.  Trans.,  vol.  xxiii.,  page  1|9. 
t  Sur  le  Diag.  et  le  Trait,  chiriu-g.  des  Etrang.  internes.    These 
de  Paris,  No.  142,  1870. 


Chap.  XXV.]  The  Treatment :  Laparotomy.         451 

no  way  be  advised.  It  must  be  done  blindly.  Its 
chances  of  failure  are  not  equalled  by  its  chances  of 
success.  In  many  cases  it  must  leave  the  real  cause 
of  the  obstruction  untouched.  It  must  expose  the 
patient  to  a  great  risk  of  faecal  extravasation  when 
the  trochar  is  withdrawn.  The  operation  is  in  itself 
dangerous,  and  at  the  most  resolves  itself,  if  success- 
ful, into  an  enterotomy  performed  in  the  dark. 

L:Bp:ii'otoiny. — This  is  one  of  the  most  important 
operations  concerned  in  the  treatment  of  intestinal 
obstruction,  and  is  a  procedure  that  is  likely  in  the 
future  to  occupy  a  still  more  conspicuous  position  than 
it  does  at  i)resent. 

It  consists  essentially  in  making  an  opening  into 
the  cavity  of  the  abdomen.  It  has  been  adopted  in 
cases  of  obstructioD  witli  many  different  purposes. 
Laparotomy  may  be  performed  merely  as  an  explo- 
ratory operation  and  as  a  means  of  diagnosis. 
As  a  measure  in  treatment  it  has  Ijeen  applied  to 
cases  of  acute  strangulation  of  all  kinds.  It  has  been 
used  as  a  means  of  dividing  constricting  bands  and 
ligaments,  of  reducing  portions  of  intestine  that  have 
become  strangulated  through  holes  and  apertures  of 
various  kinds,  of  treating  every  species  of  internal 
hernia,  of  reduction  en  masse  after  external  hernia,  of 
strangulation  by  the  diverticulum,  and  by  an  adherent 
appendix  vermiformis  and  the  like.  It  has  been 
applied  for  the  relief  of  cases  of  volvulus  and  for 
the  reduction  of  all  forms  of  intussusception.  By  its 
means  relief  has  been  aftbrded  in  examples  of  obstruc- 
tion by  impacted  foreign  })odies,  and  in  occlusion  of 
the  bowel  by  tumours  situated  without  the  intestine. 

It  has  been  made  a  preliminary  to  other  operations 
such  as  enterotomy,  enterectomy,  colectomy,  and  the 
like. 

The  principal  details  of  the  operation  will  be  dis- 
cussed when  dealing  with  the  forms  of  obstruction  to 


452  Intestinal  Obstruction.      [Chap.xxv. 

which  it  may  be  considered  to  be  applicable.  In  this 
place  it  will  be  convenient  to  consider  the  general 
features  of  the  procedure. 

The  first  question  that  arises  is  as  to  the  position  of 
the  incision.  Is  it  to  be  made  in  the  middle  line  or 
ovei'  the  seat  of  the  supposed  obstruction  %  In  answer 
to  this  question  it  may  be  said  that  in  all  cases  it 
is  better  for  the  incision  to  be  made  in  the  middle 
line,  and  this  applies  as  well  to  exploratory  as  to 
curative  procedures.  The  incision  made  in  the  linea 
alba  is  a  simple  one ;  no  important  structures  are 
cut  through ;  no  vessels  of  any  magnitude  are  divided ; 
the  abdominal  cavity  is  readily  reached  ;  the  wound 
is  not  a  deep  one,  and  after  the  operation  its  edges 
can  be  easily  apj)roximated.  If  the  incision  be 
made  over  the  supposed  seat  of  obstruction  it 
is  probable  that  the  abdominal  muscles  will  have  to 
be  cut  through ;  important  planes  of  connective  tissue 
will  thus  have  to  be  opened  up ;  vessels  that  may 
cause  troublesome  bleeding  are  apt  to  be  divided  ;  by 
the  time  the  abdomen  is  oj^ened  the  wound  will 
be  a  deep  one  and  will  have  to  be  relatively  larger 
than  the  median  wound  in  order  to  obtain  an 
equally  extensive  display  of  the  interior  of  the  belly. 
Moreover,  wounds  through  muscular  layers  are  not  so 
easy  to  adjust,  and  in  the  case  of  the  abdomen  are 
more  likely  to  lead  to  hernia  than  is  a  median  wound 
through  a  dense  fibrous  structure.  Moreover,  the 
incision  over  the  supposed  seat  of  obstruction  involves 
a  very  accurate  diagnosis,  and  failing  this  accuracy 
many  serious  errors  have  been  made.  Thus  tumours 
have  been  cut  down  upon  which  have  proved  to  be  in 
no  way  connected  with  the  obstruction.  An  incision 
has  been  made  in  the  left  iliac  region  when  the 
intestinal  stoppage  has  been  in  the  right  iliac  district. 

In  one  case  of  laparotomy  for  intussusception  tlie 
operation  had  to  be  practically  abandoned  because  the 


Chap.  XXV.]  The  Treatment:  Laparotomy.         453 

incision  had  been  made  in  a  lateral  segment  of  the 
abdomen,  and  the  surgeon's  manipulations  were  in 
consequence  seriously  restricted.  The  operator  in 
this  instance  (Mr.  George  Brown)  expressed  a  resolve 
in  his  report  of  the  case  to  operate  for  the  future  by 
a  median  incision."^ 

Even  in  cases  where  the  obstruction  is  supposed 
to  depend  upon  some  morbid  condition  in  the  loop  of 
gut  reduced  from  an  external  hernia  it  is  better  as  a 
rule  to  make  the  cut  in  the  middle  line  than  over  the 
seat  of  the  hernia.  A  cut  into  the  abdomen  through 
the  region  of  the  inguinal  canal  is  apt  to  seriously 
weaken  a  part  already  weak  and  render  very  probable 
a  subsequent  ventral  hernia.  It  moreover  greatly 
limits  the  surgeon's  sphere  of  action  and  may  render 
the  operation  useless  should  an  error  have  been  made 
in  the  diagnosis. 

Thus  in  cases  supposed  to  depend  upon  an  ex- 
ternal hernia  an  incision  has  been  made  over  the 
sac  ;  nothing  has  been  found  of  note  ;  the  wound  has 
been  closed,  and  a  second  cut  made  in  the  linea  alba.f 

Through  a  median  incision  made  between  the 
umbilicus  and  the  pubes  all  parts  of  the  abdomen  can 
be  reached  and  all  parts  of  the  intestine  explored. 
If  the  obstruction  is  not  in  the  situation  in  which  it 
was  expected  to  be  found,  it  may  be  searched  for 
elsewhere.  Any  part  of  the  small  intestine  may  be 
resected  through  a  median  wound.  I  have  shown 
that  a  part  of  the  colon  can  be  excised  through  a  like 
incision.  % 

The  most  varied  forms  of  intussusception  have 
been  reduced  through  a  cut  in  the  linea  alba,  and 
enterotomy  has  been  performed  at  the  same  situation. 
It  has  been  shown,  moreover,  that  a  primary  median 

*  Lancet,  vol.  ii.,  1882,  i^age  1036. 

t  Bee  case  by  Mr.  Bradley  ;  Lancet,  vol.  i.,  1878,  page  493. 

X  Med.-Chir.  Trans.,  vol.  Ixvi.,  1883. 


454  Intestinal  Obstruction.      [Chap.  xxv. 

incision  does  not  compromise  the  success  of  a  sub- 
sequent lumbar  colotomy.*  Lastly,  in  cases  where  a 
laparotomy  has  been  performed  when  no  such  pro- 
ceeding should  have  been  undertaken  (and  of  this 
there  are  not  a  few  examples),  it  must  be  owned  that 
the  median  incision  inflicts  the  less  serious  lesion  upon 
the  patient. 

Some  surgeons  have  suggested  that  the  abdomen, 
when  distended,  should  be  punctured  before  the 
operation.  The  evacuation  of  distended  intestines 
certainly  greatly  simplifies  the  procedure,  and  in  cases 
of  extreme  meteorism  this  preliminary  tapping  should 
be  adopted.  In  less  severe  cases  of  distension  and  in 
cases  where  there  is  reason  to  expect  a  much  damaged 
state  of  the  gut  the  puncturing  may  very  well  be 
left  until  the  intestines  have  been  themselves  exposed. 
After  such  exposure  the  puncture  may  be  made  with 
more  precision,  even  if  over  a  somewhat  more  limited 
area.  On  two  occasions  I  have  introduced  my  hand 
into  the  belly  as  soon  as  the  incision  was  large 
enough,  and  have  punctured  through  the  skin  dis- 
tended coils  that  I  could  feel  but  that  were  out  of 
easy  reach  through  the  incision. 

The  length  of  the  wound  must  depend  upon  the 
merits  of  the  indi^ddual  case.  In  most  instances  it 
should  be  at  least  large  enough  to  allow  of  the 
introduction  of  the  hand. 

The  bladder  should  be  emptied  before  the  opera- 
tion, and  in  some  cases  of  pelvic  adhesions  it  is  well 
to  make  out  its  precise  position  with  a  sound. 

In  one  reported  case,  in  a  male  patient,  the  bladder 
was  cut  into  during  the  preliminary  incision  and  urine 
escaped  into  the  peritoneal  cavity.    The  j^atient  died,  f 

*  See,  for  example,  case  by  Mr.  Pitts  ;  St.  Thomas's  Hosp;  Re- 
ports, vol.  xi;,  1882,  page  75, 

t  Case  by  Dr.  Atherton  ;  Boston  Med.  and  Surp.  Jonrn.,  1883, 
page  .5S1 . 


Chap.  XXV.]  The  Treatment :  Laparotomy.         455 

When  the  abdomen  has  been  opened  great  care 
must  be  taken  to  prevent  the  protrusion  of  the  dis- 
tended viscera.  I  am  convinced  that  such  protru- 
sion very  seriously  compromises  the  success  of  the 
operation,  and  I  think  that  this  fact  is  demonstrated 
by  the  recorded  cases. 

The  practice  of  allowing  the  bowels  to  escape  for 
the  purpose  of  more  readily  finding  the  obstruction  is 
absolutely  bad.  The  protrusion  should  be  prevented 
by  an  assistant  provided  with  one  or  more  large  flat 
sponges  that  have  been  soaked  in  warm  carbolic  water. 
When  these  sponges  become  cool  they  should  be 
changed.  Some  surgeons  appear  to  have  used  flannels 
wrung  out  in  hot  water  for  this  purpose.  A  more  un- 
suitable material  could  hardly  be  imagined,  since  the 
hairy  particles  of  the  flannel  adhere  to  the  intestine 
with  the  greatest  readiness  and  are  only  to  be  got  rid 
of  with,  difficulty. 

The  hand  should  be  introduced  into  the  abdomen, 
and  before  such  introduction  greatly  distended  coils 
miay  be  evacuated  by  a  fine  capillary  trochar  if  deemed 
advisable.  I  would  strongly  urge  that  the  examina- 
tion should  now  be  conducted  on  the  following  syste- 
matic principles,  even  in  cases  where  the  diagnosis  is 
considered  to  be  fairly  certain.  The  hand  should  first 
be  passed  to  the  csecum.  If  this  part  of  the  intestine 
be  found  to  be  greatly  distended  the  obstruction  may 
be  taken  to  be  in  the  colon  ;  but  if  it  be  found  to  be 
empty,  or  only  moderately  filled,  then  it  may  be  con- 
cluded that  the  stoppage  is  in  the  lesser  bowel.  Thus 
with  very  little  disturbance  of  parts  a  considerable 
step  may  be  made  towards  a  cori-ect  diagnosis. 

The  csecum  may  not  be  found,  either  because  it  is 
the  subject  of  congenital  malposition,  or  because  it  has 
become  involved  in  an  intussusception  or  a  volvulus. 

If  from  the  condition  of  the  csecum  it  is  sur- 
mised that  the  obstruction  is  in  the  colon,  then  the 


456  Intestinal  Obstruction.      [Chap. xxv. 

hand  must  be  passed  along  the  whole  length  of  that 
intestine,  from  its  commencement  to  the  beginning  of 
the  rectum.  The  rectum  itself  will,  of  course,  have 
been  explored  previous  to  the  operation. 

If  the  condition  of  the  caecum  points  rather  to  an 
obstruction  in  the  lesser  bowel,  then  a  somewhat  more 
difficult  examination  has  to  be  undertaken.  Some 
operators  have  avoided  the  difficulty  by  allowing  the 
intestine  to  protrude  and  by  then  searching  in  the  ab- 
domen for  the  obstruction.  Such  a  procedure  is  very 
strongly  to  be  condemned.  Another  plan  is  to  expose 
in  the  depth  of  the  wound  the  length  of  the  small  in- 
testine inch  by  inch  until  the  part  occluded  is  reached. 
The  serious  difficulty  in  this  case  is  usually  a  lack  of 
knowledge  of  the  precise  portion  of  bowel  first  exposed. 
Without  this  knowledge  the  surgeon  may  proceed 
with  his  examination  in  the  wrong  direction  and  find 
himself  at  the  end  of  a  tedious  inspection  at  the  duo- 
denum. Quite  recently  Mr.  Rand  of  Liverpool  has 
advised  an  examination  of  the  root  of  the  mesentery 
as  a  means  of  recognising  any  given  portion  of  intes- 
tine exposed.*  It  is  well  known  that  the  attached 
edge  of  the  mesentery  is  only  about  six  inches  in 
length,  and  that  it  extends  along  the  spine  from  the 
left  side  of  the  second  lumbar  vertebra  to  the  right 
sacro -iliac  synchondrosis.  Mr.  Rand  advises  that  the 
mesentery  of  the  exposed  piece  of  gut  be  examined, 
and  claims  that  by  this  examination  it  would  be  pos- 
sible to  find  which  was  the  upper  and  which  the  lower 
end  of  the  coil,  and  also  to  form  some  idea  as  to  whether 
it  belonged  to  the  higher  or  to  the  terminal  parts  of 
the  lesser  bowel.  This  plan  may  succeed  in  a  few  in- 
stances, but  in  many  it  would  be  of  little  avail,  as  in 
cases  where  many  adhesions  exist,  or  where  there  is 
m  uch  shrinking  of  the  mesentery,  or  where  a  volvulus 
has  occurred.  By  far  the  readier  way  out  of  the 
*  British  Med.  Journ.,  Dec.  22nd,  1883,  page  1235. 


Chap.  XXV.]  The  Treatment :  Laparotomy.         457 

difficulty  is  to  commence  the  examination,  not  with 
the  distended  coils  that  present  in  the  wound,  but  with 
the  empty  and  collapsed  coils  below  the  obstruction. 
When  the  obstruction  is  complete  there  should  be 
no  difficulty  in  recognising  such  coils.  In  cases 
of  strangulation  involving  the  lower  ileum  these 
emjjty  loops  of  intestine  should  be  sought  for  in 
the  ciecal  region.  When  the  obstruction  is  higher 
iij)  in  the  bowel  the  collapsed  loops  are  extremely 
apt  to  hang  down  into  the  pelvis.  It  is  well,  there- 
fore, that  a  search  for  the  obstruction  in  the  small 
intestine  should  commence  with  a  search  for  non- 
distended  coils  in  the  region  of  the  c?ecum,  or  about 
the  brim  of  the  pelvis,  or  within  that  cavity.  This 
method  of  investigation  was  first  proposed,  so  far  as  I 
can  ascertain,  by  Mr.  Hulke  in  1872.  In  describing  a 
case  of  laparotomy  he  says,  "I  passed  in  my  hand 
and  felt  for  an  empty  piece  of  small  intestine,  by 
tracing  which  I  hoped  to  be  led  to  the  obstruction."  "^ 
In  another  case  of  Mr.  Hulke's,  reported  by  Dr. 
J,  K.  Fowler,  this  i^rocedure  was  carried  out,  and  Dr. 
Fowler  makes  a  point  of  strongly  advocating  the 
method.!  As  he  observes,  the  collapsed  gut  can  be 
examined  with  ease  and  rapidity,  the  distended  and  en- 
gorged bowel  above  the  obstruction  is  not  exposed  to 
an  extensive  handling,  and  the  risk  of  rupturing  these 
dilated  coils,  a  risk  by  no  means  slight,  is  thus  avoided. 
Certainly  by  this  means  the  danger  of  peritonitis  is  re- 
duced to  a  minimum.  A  third  case  of  laparotomy  by 
Mr.  Hulke  serves  to  illustrate  indirectly  the  value  of 
this  method.  In  this  case  pains  were  taken  not  to 
allow  the  bowels  to  protrude.  The  small  intestine 
was  drawn  to  the  wound  and  examined  inch  by  inch, 
and  the  loop  so  inspected  reduced  after  its  exposure. 
Unfortunately    the    examination  Avas    in   the    wrong 

*  Med.  Times  and  Gazette,  vol.  ii. ,  1872,  page  482. 
\  Lancet,  vol.  i.,  1883,  page  1119. 


458  Intestinal  Obstruction.      [Chap.  xxv. 

direction,  and  after  a  time  the  duodenum  was  reached, 
and  before  the  obstruction  was  found  the  whole  process 
of  examination  had  to  be  reversed.* 

In  any  case  where  hernia  is  suspected  the  various 
hernial  orifices  should  be  examined  from  within.  They 
can  all  be  readily  reached  by  the  hand  introduced 
through  the  median  incision. 

The  special  treatment  to  be  adopted  when  the  ob- 
struction has  been  found  will  be  considered  subse- 
quently, when  dealing  with  the  treatment  of  the 
varieties  of  obstruction. 

After  the  operation  the  peritoneal  cavity  should  be 
well  sponged  out.  The  wound  should  be  united  in  the 
same  manner  as  the  wound  after  ovariotomy.  The 
best  suture  material  is  "  Chinese  twist."  For  conve- 
nience of  introduction  each  suture  should  be  threaded 
at  either  end  to  a  long  straight  needle.  Deep  sutures, 
to  include  the  peritoneum,  should  be  placed  at  inter- 
vals of  about  half  an  inch.  The  intermediate  parts  of 
the  wound  may  be  adjusted  by  superficial  sutures. 
With  regard  to  the  draining  of  the  peritoneal  cavity 
after  the  operation,  the  matter  remains  in  the  same 
position  somewhat  as  the  question  of  drainage  after 
ovariotomy.      Some  advise,  others  condemn. 

I  think  that  in  cases  where  peritoneal  inflammation 
is  to  be  expected  a  drain  should  certainly  be  intro- 
duced. 

In  the  above  observations  I  have  presumed  that  the 
operation  is  performed  under  the  strictest  antiseptic 
precautions.  It  would  certainly  appear  that  lapar- 
otomy has  been  attended  with  greater  success  since 
the  introduction  of  Listerism.  At  the  same  time  it 
must  be  remembered  that  with  every  year  our  know- 
ledge of  the  diagnosis  of  these  cases  has  become  more 
accurate. 

There  are  many  possible  fallacies  in  the  operation. 

*  Path.  Soc.  Trans.,  vol.  xxxiii.,  page  146. 


Chap.  XXV.]  The  Treatment :  Laparotomy.         459 

In  several  instances  there  has  been  no  real  obstruction, 
bat  the  symptoms  have  been  all  clue  to  acute  perito- 
nitis."^ In  one  case,  at  least,  no  cause  of  obstruction 
was  found,  the  patient  had  no  peritonitis.  The  wound 
was  closed  and  the  patient  recovered.!  In  other  in- 
stances there  has  been  an  obstruction  but  it  has  been 
overlooked  and  the  patient  has  died  unrelieved.  ±  In 
man  J  examples  of  the  operation  the  obstruction  was 
found  but  was  of  a  nature  not  to  be  relieved  and  the 
case  was  practically  abandoned.  Some  of  these  were 
cases  of  volvulus  of  the  colon,  others  were  examples  of 
extensive  cancer,  and  others  of  stricture.  § 

In  many  instances  also  the  obstruction  was  of  such 
a  nature  that  it  could  be  only  relieved  by  some  further 
operation  such  as  enterotomy  or  colotomy. 

When  two  forms  of  obstruction  exist  in  the  same 
case  one  is  very  apt  to  be  treated  and  the  other  to  be 
overlooked.  In  several  examples  where  two  bands 
have  obstructed  the  intestine  at  the  same  time,  only 
one  band,  and  that  causing  the  less  amount  of  trouble, 
has  been  divided  and  the  patient  has  died  uni^elieved. 

The  pathology  of  intestinal  obstruction  also  reveals 
cases  where  obstruction  due  to  stricture  has  been  as- 
sociated with  a  less  important  obstruction  due  to  slight 
entanglement  of  a  loop  beneath  a  band.  [|  Had  these 
cases  been  treated  by  laparotomy  it  is  more  than  prob- 
able that  the  false  ligament  would  have  been  divided 
and  the  stenosis  overlooked. 

With  regard  to  the  general  mortality  of  the 
operation,  I  have  here  collected  155  examples  of  the 

*  For  cases  see  Duplay's  monograph ;  Archives  Gen.  de  M^d. , 
vol.  xxviii. ,  1876,  page  513. 

t  Lancet,  vol.  i.,  1871,  page  776. 

X  Brit.  Med.  Journ.,  1882,  page  166. 

§  For  cases  see  Billroth  ;  Archiv  f.  klin.  Chirug.  Langenbeck, 
b.  i.,  s.  485  ;  Lawson,  Med.  Times,  vol.  i.,  1861,  page  675 ;  Spencer, 
ibid.,  1879;   Maunder,  Med.  Press,  1867. 

II  For  examples  of  such  cases  see  Path.  Soc.  Trans,,  vol.  iv., 
page  156  ;  and  Le  Progres  Medical,  1882,  page  12. 


460 


Intestinal  Obstruction.      (Chap.  xxv 


operation.  M.  Peyrot  had  collected  in  1880  125  cases.* 
In  my  list  I  have  omitted,  for  various  reasons, 
several  of  M.  Peyrot's  cases,  and  have  added  forty- 
five  new  ones. 


Laparotomy  for  Intestinal  Obstruction  exclusive  of 


Intussusception. 


Internal  hernia 


Strangulation  after  tlie  reduction  of  hernia  ■< 

Strangulation  by  bands  of  all  kinds  .        .  -j 

Volvulus ■< 

Strangulation  through  slits  or  apertures  .  -j 

Stricture,  etc \ 

Tumour  compressing  the  bowel         .        .  \ 

Strangulation  by  diverticula       .        .        .  •< 

Obstruction  by  foreign  bodies  .         .        .  ■< 

Obstruction  due  to  unknown  causes          .  ■] 

Total  number  of  laparotomies 
Total  number  of  [recoveries    .        . 
Total  number  of  deaths 

"Koi-talxt-^f  63*1  per  cent. 


3  Recoveries. 

6  Deaths. 

7  Recoveries. 
6  Deaths. 

15  Recoveries. 
31  Deaths. 

2  Recoveries. 
15  Deaths. 

1  Recovery. 

3  Deaths. 

6  Recoveries. 
5  Deaths. 

2  Recoveries. 

0  Death. 

3  Recoveries. 

8  Deaths. 

4  Recoveries. 

1  Death. 

2  Recoveries. 
2  Deaths. 

122 

45 

.       .        77 


9 

13] 
46 
17 

4 
11 

2 
11 

5 

4 


Ages  op  the  Patients. 


2  years  and  under. 

3  to  10  years. 

11  to  15  years. 

16  to  20  years. 

Recoveries        .    0 
Deaths     .        .    0 

Recoveries .    0 
Deaths         .    2 

Recoveries .    2 
Deaths        .    7 

Recoveries  .  4 
Deaths          .    9 

Total        .        .    0 

Total   .        .    2 

Total  .        .    9 

Total     .        .  13 

21  to  40  years. 

41  to  60  years. 

Over  60  years. 

Age  not  Stated. 

Recoveries     .    20 
Deaths            .    23 

Recoveries .    8 
Deaths        .  18 

Recoveries .    5 
Deaths        .    5 

Recoveries  .  6 
Deaths          .  13 

Total       .        .     43 

Total   .        .  26 

Total   .        .  10 

Total     .        .  19 

*  De  rintervention  chirurgicale  dans  I'Obstruction  intestinale. 
Paris,  1880. 


Chap.  XXV.]  The  Treatment:  Laparotomy. 


461 


Laparotomy  for  Intussusception. 


Total  uuniber  of  cases       .... 
Total  numbex*  of  recoveries 
Total  number  of  deatlis    .... 
Mortolity,  72'7  per  cent. 

Two  years  old  and  under         ...        18  cases 


33 
9 

24 


Three  to  fifteen  years  old 

Over  fifteen  years  old     . 

'Rcdi.uciion  easy. 
Total  cases    .... 
Recoveries     .... 

Deaths 

Mortality,  30  per  cent. 


10 

7 
3 


^5 


Jlecoveries. 

6  months. 

7  „ 
9        „ 

2  years. 
I  33      „  ■ 
134      „ 
L50      „ 


Deaths. 
Infant. 
9  months. 
17       .. 


4  cases 
11  cases 


f  4  recoveries. 
1. 14  deaths, 
f    0  recoveries. 
(    4  deaths. 
(    5  recoveries. 
(   6  deaths. 


Reduction  difficult  or  impossible. 
Total  cases     .        .        . "--  ,        23 
Recoveries      ....  2 

Deaths 21 

Mortality,  91*3  per  cent. 
Bccovevies.  Deaths. 

'20  years.    12  Aveeks. 


28  years. 


L 


14 

4  months. 
5 


9        „ 
1  year. 
16  months 
6^-  years. 


(2  cases.) 
(3  cases.) 


12 
14 
16 

36 
43 
50 

"Ay 


,       (2  cases.) 


ouug  man. 


Duration  of  disease  at  the  time 

laparotomy  was  performed  in  the 

cases  that  ^ver6  reduced  easily. 


18  hours. 

2  days. 

"A  few  days." 

4  days. 

5  days. 


10  cases. 


14  days. 
18  days. 
One  month. 
Not  stated 
(2  cases). 


Duration  of  disease  at  the  time 

laparotomy    was    performed    in 

the  cases  that  aucrc    irreducible 

or  difficult  of  reduction. 


48  hours. 

3  days  (2  cases). 

4  days  (2  cases) . 

5  daj's  (3  cases). 
"Under  7  days." 
7  days. 
"Some  days" 

(3  cases). 


10  days  (2  cases). 

11  days. 
17  days. 
30  days. 
One  month. 
4  months. 
Not     stated 

(3  cases). 


Since  the  preparation  of  this  table  Dr.  Schramm  *  lias 
published  statistics  of  193  laparotomies  for  intestinal 
obstruction,  including  twenty-seven  for  intussusception. 

*■  Langenbeck's  Archiv.,  band  xxx.,  heft.  4. 


462  Intestinal  Obstruction.      [Chap.  xxv. 

The  mortality  of  this  series  is  64*2  per  cent.  The 
mortality  of  the  operation  in  the  various  forms  of  ob- 
struction is  practically  the  same  as  in  the  above  table. 

Out  of  my  one  hundred  and  fifty-five  cases 
there  were  fifty-four  recoveries  and  one  hundred 
and  one  deaths.  I  believe  that  these  statistics  are 
quite  useless  as  a  means  of  ascertaining  the  real  mor- 
tality after  this  operation.  Probably  the  recorded 
cases  bear  to  those  that  are  unpublished  the  proportion 
of  one  to  ten,  and  it  may  be  surmised  that  the  great 
bulk  of  these  unpublished  cases  ended  in  death.  It  is 
scarcely  possible  to  find  any  hospital  sui'geon  of  expe- 
rience who  cannot  allude  to  two  or  three  unsuccessful 
laparotomies  for  obstruction  in  his  practice.  On 
looking  through  the  published  cases  one  is  struck  with 
the  fact  that  they  have  been  published  for  the  most 
pai-t  with  one  of  two  objects,  either  because  they  were 
successful  or  because  they  j)resented  some  interesting 
pathological  feature.  Cases  that  end  fatally  and  liave 
no  pathological  interest  in  the  eyes  of  the  operator 
are  not  reported. 

I  have  no  doubt,  therefore,  but  that  the  mortality 
after  laparotomy  is  a  very  great  deal  higher  than  that 
shown  in  the  above  statement. 

The  high  mortality  need  be  no  matter  for  wonder. 
In  the  majority  of  the  cases  the  operation  was 
performed  at  a  period  antecedent  to  the  introduction 
of  antiseptic  measures  in  surgery,  and  previous  to  the 
great  advances  that  have  been  of  late  years  made  in 
abdominal  operations. 

Thus  Dr.  Schramm  has  shown  that  the  cases  of 
laparotomy  reported  prior  to  the  year  1873  show  a 
mortality  of  73  per  cent.,  while  those  reported  since 
that  date  present  a  mortality  of  only  58  per  cent. 

A  large  number  of  the  recorded  cases  were 
totally  unfit  for  operation.  Some  of  the  patients 
were  almost  moribund  at  the  time  the  laparotomy 


Chap.  XXV.]  The  Treatment :  Laparotomy.         463 

was  performed,  others  were  in  a  condition  of  pro- 
found exhaustion.  In  some  there  was  general  acute 
peritonitis,  in  others  fsecal  extravasation  had  already 
occurred  before  the  abdomen  was  opened.  Lapar- 
otomy has  been  done  in  cases  where  treatment  had 
been  so  long  delayed  that  the  gut  was  gangrenous 
and  became  ruptured  when  handled.  Laparotomy  has 
indeed  been  looked  upon  as  a  last  resource  instead  of 
as  a  primary  measure,  and  in  the  face  of  the  above 
facts  it  can  hardly  be  wondered  that  the  mortality 
after  the  operation  has  been  high. 

Dr.  Schramm  has  given  a  table  in  the  monograph 
above  referred  to,  to  show  the  influence  that  the  time 
of  performing  the  operation  has  upon  the  result. 
This  table  shows  in  a  graphic  manner  how  serious  is 
the  delay,  even  of  twenty-four  hours,  when  lapar- 
otomy is  concerned. 

An  examination  of  the  recorded  cases  shows  very 
clearly  that  in  proper  instances,  and  especially  in  those 
where  the  operation  is  undertaken  early  enough,  lapar- 
otomy is  by  no  means  so  very  fatal  a  procedure.  The 
one  great  fact  that  aifects  the  issue  of  the  operation  is 
not  so  much  the  age  of  the  patient,  nor  the  seat  of  the 
obstruction,  nor  the  period  in  the  disease  when  the 
procedure  was  carried  out,  but  the  state  of  the  gut  j 
and  since  pathology  can  give  us  precise  teaching  upon 
this  latter  point,  there  is  no  reason  why  laparotomy 
should  not  be  rescued  from  the  somewhat  ignominious 
position  it  now  occupies  in  surgery. 

There  is  no  reason  why  in  the  future,  with  a  fuller 
knowledge  of  the  technical  details  essential  to  the  ope- 
ration, with  a  surer  acquaintance  with  the  clinical 
aspects  of  obstruction,  and  with  the  exercise  of  a 
sounder  judgment  in  the  selection  of  cases,  the  proce- 
dure of  laparotomy  should  not  have  a  mortality  but 
little  higher  than  that  of  the  operation  for  the  relief  of 
strangulated  hernia. 


464  Intestinal  Obstruction.      [Chap. xxv. 

liaparotomy  during:  peritonitis.— The  gene- 
ral question  may  now  be  considered  as  to  how  far  peri- 
tonitis is  a  bar  to  operation  in  cases  of  obstruction  of 
the  intestines. 

It  may  be  at  once  said  that  when  peritonitis  occurs 
in  connection  with  intestinal  obstruction  its  appearance 
usually  coincides  with  so  serious  a  condition  of  the 
gut  that  the  case  is  unfit  for  any  kind  of  operation. 
The  intestine  under  such  circumstances  maybe  intensely 
inflamed  or  gangrenous,  or,  as  is  frequently  the  case, 
perforated.  Thus  it  happens  that  laparotomy  per- 
formed during  peritonitis  has  been  in  nearly  every  case 
fatal,  and  the  same  applies  to  other  operations  for  the 
relief  of  obstruction,  such  as  enterotomy. 

Duplay  has  collected  several  cases  of  laparotomy 
performed  for  a  peritonitis,  the  symptoms  of  which  were 
mistaken  for  those  of  acute  strangulation.  These  were 
all  instances  of  perforative  peritonitis,  and  all  led  to  a 
fatal  result.  I  have  been  able  to  add  several  other 
cases  to  Duplay's  list,  and  they  collectively  serve  to 
show  that  (at  the  present  time  at  least)  abdominal 
incision  does  not  delay  the  fatal  issue  in  cases  of  per- 
forative peritonitis,  and  that  all  operations  performed 
during  that  condition  are  entirely  hopeless. 

The  occurrence,  however,  of  local  peritonitis,  and 
even  of  acute  general  peritonitis,  when  not  due  to  per- 
foration, is  not  an  absolute  bar  to  the  performance  of 
laparotomy  for  the  relief  of  obstruction,  as  some  recent 
cases  show. 

I  have  found  two  recorded  instances  of  laparotomy 
performed  during  acute  general  peritonitis,  in  both  of 
which  the  obstruction  was  relieved,  and  the  patients 
made  an  excellent  recovery.  It  is  significant  that  in 
both  these  cases  the  operation  was  carried  out  under 
strict  antiseptic  precautions.  The  first  case  w;is  re- 
corded by  M.  Terrier.  It  concerned  a  female,  aged 
twenty-one,  who  was  operated  upon,  upon  the  third 


Chap.  XXV.]   The  Treatment :  Laparotomy.       465 

day  of  the  symptoms,  for  the  relief  of  a  strangulation 
by  a  band.  Much  sero-sangiiinolent  fluid  escaped  from 
the  peritoneal  cavity,  the  serous  membrane  was  red, 
and  the  intestines  extensively  adherent  by  soft  recent 
adhesions.  The  band  was  found  and  divided  without 
diliiculty.'^  The  second  case  was  by  M.  JuUiard.  The 
patient,  a  woman  aged  forty-eight,  had  an  ovarian 
tumour,  and  developed  symptoms  of  obstruction. 
Laparotomy  was  performed  on  the  second  day.  The 
ovarian  growth  was  removed  and  the  o])struction, 
which  was  due  to  oldish  adhesions,  was  relieved.  The 
peritoneum  was  in  about  the  same  condition  as  in  the 
previous  case.f 

Apropos  of  this  subject  it  may  be  observed  that  the 
practice  is  gaining  ground  of  treating  many  cases  of 
peritonitis  by  free  incision  and  drainage.  This  treat- 
ment has  been  applied  to  inflammatory  effusions  into 
another  large  serous  cavity,  that  of  the  pleura,  and 
why  not  to  the  peritoneum  %  The  cases  that  appear  to 
be  best  suited  for  such  treatment  are  cases  of  chronic 
peritonitis  and  especially  of  local  peritonitis.  So  far 
as  I  can  ascertain,  the  first  serious  proposal  that  ab- 
dominal section  should  be  performed  for  peritonitis 
was  brought  forward  by  the  late  Mr.  Hancock  in  a 
paper  read  before  the  Medical  Society  in  1848.  Mr. 
Hancock  opened  the  abdomen  in  a  case  of  chronic  local 
peritonitis  depending  upon  some  disease  in  the  ap- 
pendix, and  the  patient  recovered.  In  his  comments 
upon  the  case  Mr.  Hancock  remarks  :  "I  trust  the 
time  will  come  when  this  plan  will  be  successfully  em- 
ployed in  other  cases  of  peritonitis."  Mr.  Lawson 
Tait  has  performed  abdominal  section  in  several  cases 
of  chronic  peritonitis,  with  a  good  result  in  each  in- 
stance. |      Dr.   Savage  reports  eight    cases  of  pelvic 

*  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1879,  page  564. 
t  Ibid,,  page  665. 

Ij:  Brit.  Med.  Journ.,  Feh.  17th,  1883,  page  300. 
E  E — 12 


466  InTES  TINA  L    ObS  TR  UC  TION.         [Chap .  XX V. 

peritonitis  treated  by  laparotomy,  and  all  followed  by  a 
successful  issue. "^  In  a  case  of  chronic  puerperal 
2)eritonitis  Dr.  Playfair  made  an  abdominal  incision 
and  freely  drained  the  serous  cavity  under  antiseptic 
precautions,  with  a  perfectly  successful  result,  f 

One  of  the  most  interesting  cases,  however,  that 
can  be  mentioned  in  the  present  category  is  placed  on 
record  by  Dr.  Buchanan  of  Glasgow.  A  woman  of  29 
years  of  age  was  suddenly  seized  with  severe  abdominal 
pain,  soon  followed  by  vomiting.  The  attack  came  on 
on  Feb.  18th,  at  2  a,m.,  after  eating  a  hearty  supper. 
The  pain  and  vomiting  became  more  severe,  and  at 
4  a.m.  on  Feb.  20th  the  ejected  matters  were  stercora- 
ceous.  There  was  absolute  constipation,  and  enemata 
gave  no  relief.  On  Feb.  21st  the  patient  was  greatly 
l)rostrated,  the  eyes  were  sunken,  the  voice  husky,  the 
limbs  cold.  The  case  was  considered  to  be  one  of 
obstruction.  Median  laparotomy  was  performed  (non- 
antiseptic).  One  pint  of  turbid  serum  containing 
curd-like  iiocculi  escaped.  There  were  extensive  recent 
adhesions  invohdng  all  the  intestines.  No  obstruction 
was  found.  The  pelvis  was  sj)onged  out  and  the 
wound  closed.  The  patient  made  an  excellent 
recovery.  \ 

Eiitei'Otoniy. — This  operation  was  first  proposed 
and  carried  out  by  Nelaton,  by  whose  name  it  is  also 
very  usually  called.  The  procedure  is  as  follows  :  The 
seat  of  the  operation  is  the  iliac  or  inguinal  region, 
preference  being  given  to  the  right  side.  An  incision 
is  made  through  the  abdominal  parietes  parallel  to 
and  a  little  above  Poupart's  ligament,  and  to  the 
outer  side  of  the  epigastric  artery.  The  skin  incision 
is  advised  to  be  about  7  cm.  in  length.      The  deep 

*  Brit.  Med.  Journ.,  March  4th,  1884. 

t  Ibid.,  INIarch  10th,  1883.  See  also  account  of  Dr.  Moloden- 
koff' s  fatal  case  in  au  annotation  in  the  same  journal,  Feb.  10th, 
1883. 

X  Lancet,  vol.  i.,  1871,  page  776. 


Chap.  XXV.]  The  Treatment :  Enterotomy.       467 

incision  whereby  tlie  peritoneum  is  opened  being  about 
4  cm.  in  lensrtli.  The  first  distended  coil  of  bowel 
that  presents  itself  is  gently  seized  and  drawn  into  the 
wound.  If  the  operation  be  performed  upon  the  right 
side  it  is  found  that  the  segment  of  intestine  opened  is 
nearly  always  the  terminal  part  of  the  ileum.  The 
gut  is  then  fixed  to  the  wound  by  a  double  line  of 
sutures  which  transfix  the  intestinal  walls.  An  opening 
is  finally  made  into  the  bowel  between  the  two  lines  of 
suture  and  the  operation  is  completed. 

In  chronic  cases,  where  time  may  be  no  great  object, 
the  operation  can  be  divided  into  two  stages.  In  the 
first  stage  the  gut  is  fixed  to  the  sides  of  the  incision 
by  a  series  of  sutures  that  do  not  traverse  the  entire 
thickness  of  the  intestinal  wall.  Three  or  four  days 
are  allowed  to  elapse  in  order  that  adhesions  may  form 
between  the  bowel  and  the  parietal  peritoneum,  and 
then  by  a  second  slight  operation  the  gut  is  opened 
and  secured,  if  necessary,  by  more  substantial  ligatures. 
The  first  stage  [in  the  procedure  may  be  conducted 
under  antiseptic  precautions. 

Enterotomy  is  an  operation  that  can  be  very 
readily  performed  and  that  is  fairly  certain  of  success 
so  far  as  making  an  opening  in  the  gut  above  an 
obstruction  is  concerned.  It  involves  no  more  expo- 
sure of  the  peritoneum  than  pertains  to  the  operation 
of  kelotomy  when  the  sac  is  opened. 

The  procedure  has  been  carried  out  in  nearly  every 
form  of  intestinal  obstruction,  and  has  certainly  been 
more  popular  upon  the  continent  than  in  this  country. 

It  has  been  done  for  internal  strangulation,  for 
volvulus,  for  intussusception,  both  acute  and  chronic, 
for  the  many  forms  of  obstruction  due  to  adhesions, 
for  fsecal  accumulation,  for  stricture,  and  for  obstruc- 
tion by  foreign  bodies.  It  has  also  been  performed, 
owing  to  an  error  in  diagnosis,  in  a  case  of  tubercular 
peritonitis.     In  some  instances  the  opex^ation  has  been 


468  Intestinal  Obstruction.      LChap.xxv. 

secondary  to  another  procedure.  For  example,  a 
laparotomy  lias  been  performed  to  relieve  a  supposed 
strangulation.  The  case  has  proved  to  be  incap- 
able of  relief  by  the  means  intended,  and  an  enter- 
otomy  has  then  been  performed.  Messrs.  Morris  and 
Coupland,  in  their  monograph  upon  stricture  of  the  in- 
testine, advise  that  when  a  lumbar  colotomy  has  been 
performed,  and  it  is  found  that  the  colon  has  been 
oj3ened  heloio  the  obstruction,  the  peritoneum  should 
be  incised,  and  a  coil  of  small  intestine  pulled  into  the 
lumbar  wound  and  opened. 

I  cannot  avoid  the  conclusion  that  a  primary  en- 
terotomy  is  not  to  be  advised.  The  operation  is  at  the 
best  but  a  palliative  measure ;  it  is  not  founded  upon 
sound  surgical  principles ;  it  is  a  procedure  that  is 
carried  out  more  or  less  independently  of  diagnosis ; 
it  is  an  operation  done  in  the  dark,  and  it  leaves  the 
cause  of  the  disorder  untouched.  It  is  true  that  it  does 
not  show  so  high  a  mortality  as  does  laparotomy,  but 
the  disadvantages  of  the  procedure  are  many.  In  the 
first  j^lace,  as  already  stated,  it  leaves  the  real  malady 
itself  untouched.  To  this  statement  there  are  a  few 
exceptions.  There  are  some  forms  of  obstruction  that 
are  in  great  measure  jDroduced  and  maintained  by  dis- 
tension of  the  bowel ;  among  such  are  certain  forms  of 
volvulus  (which  are  very  rare),  some  cases  of  occlusion 
by  kinking,  by  adhesions,  and  by  changes  in  the  visceral 
peritoneum  or  mesentery.  Such  cases  iniay  be  cured 
by  enterotomy,  and  a  closure  of  the  artificial  anus  may 
follow  the  oi)eration.  Some  cases  also  of  fa3cal  accu- 
mulation and  of  obstruction  by  a  foreign  substance  may 
be  so  far  relieved  by  enterotomy  that  the  artificial 
anus  may  close  in  time,  or  be  closed  by  some  plastic 
measure.  But  how  stands  the  matter  in  other  cases  % 
The  obstruction  remains.  If  it  be  an  example  of  acute 
strangualtion,  or  of  volvulus,  or  of  intussusception, 
then  the  gut  may  become  in  time  gangrenous,  and  the 


Chap.  XXV.]  The  Treatment :  Enterotomy.       469 

patient  die  practically  of  the  direct  effects  of  an  unre- 
lieved, or  imperfectly  relieved,  obstniction  of  the  bowel. 
If  the  obstruction  be  due  to  cancer,  the  cancer  is  left 
untouched,  and  the  operation  merely  gives  some  tem- 
porary relief.  Suppose,  however,  that  after  the  enter- 
otomy no  farther  changes  of  a  destructive  or  malignant 
character  take  place  about  the  seat  of  obstruction ; 
what  is  the  condition  of  the  patient  ]  There  is  a  per- 
manent fsecal  fistula  in  the  groin.  This  leads  into  the 
small  intestine,  and  may  be  the  cause  of  wasting,  and, 
if  higher  up  in  the  bowel  than  usual,  of  death  from 
marasmus.  There  may  be,  moreover,  a  considerable 
portion  of  intestine  between  the  artificial  anus  and  the 
obstruction,  and  the  accumulation  of  fa3cal  matter  in 
this  part  of  the  bowel  may  lead  to  the  greatest  distress. 
The  ileum  has  actually  been  opened  to  relieve  a  case, 
not  diagnosed  at  the  time,  of  simple  stricture  in  the 
upper  part  of  the  rectum,  and  in  other  examples  of 
enterotomy  the  seat  of  the  obstruction  has  been  in  the 
descending  colon  and  the  sigmoid  fiexure. 

An  operation  that  would  present  examples  such  as 
these  cannot  be  said  to  be  based  upon  proper  surgical 
principles. 

Against  secondary  enterotomies  there  is  nothing  to 
be  said.  If  in  performing  a  lumbar  colotomy  it  is 
found  that  the  colon  has  been  exposed  at  a  point  below 
the  obstruction,  then  it  is  clearly  better  to  open  the 
small  intestine  at  the  seat  of  the  colotomy,  if  the  case 
be  urgent,  rather  than  to  make  a  second  attempt  upon 
the  colon  in  another  place.  These  remarks  refer  in 
the  main  to  lumbar  colotomy  of  the  ascending  colon, 
in  cases  where  the  stricture  is  in  the  csecum  or  in  the 
terminal  part  of  the  ileum. 

Moreover,  when  a  laparotomy  has  been  performed, 
there  are  many  cases  in  which  nothing  can  be  done  to 
give  relief  save  by  enterotomy  or  enterectomy,  and  by 
some  secondary  enterotomies  it  is  certain  that  life  has 


47 o  Intestinal  Obstruction.      [Chap.  xxv. 

been  spared  and  the  patient's  existence  has  been  greatly 
prolonged. 

The  following  statistics  deal  with  the  mortality 
after  enterotomy.  The  cases  are  divided  into  two  sets, 
those  in  which  the  operation  was  done  for  cancer,  and 
those  in  which  it  was  done  for  obstruction  due  to  non- 
malignant  disease.  The  total  number  of  cases  is  109. 
Of  these,  ^^  are  taken  from  Peyrot's  tables,  the 
remaining  23  I  have  collected  myself,  mainly  from 
reports  subsequent  to  the  date  of  Peyrot's  monograph. 
They  serve  to  show  the  great  mortality  of  enterotomy 
in  cancer,  and  also  demonstrate  the  fact  that  in  the 
fatal  cases  death  does  not  follow  so  soon  after  the 
operation  as  it  does  in  fatal  cases  of  laparotomy,  where 
the  great  majority  of  the  deaths  fall  within  the  first 
twenty -four  hours. 


Sixty-one  operations         ....        j  20  ^re^described  as  cured. 

j'24  died  within  2    days      of    the    operation. 
Of  the  fatal  cases       .     •<    7     ,,  ,,        2  to  5  „  „ 

(  6     „  „        6  to  10 

Four  patients  survived  the  operation  respectively  11  days,  15  days, 
22  days,  and  2  months. 

Enterotomy  in  Cases  of  Malignant  Strictuke. 

Forty-eight  operations     ....        |  J  are^described  as  cured. 

("28  died  within   2    days    of    the    operation. 
Of  the  fatal  oases       ,    ■?    6     „  „        2  to  5  ,,  „ 

(.  1     „  »        6  to  10 

Seven  patients  survived  the  operation  respectively  12  days,  28  days, 
2  months,  4  mouths,  6  months  (two  cases),  and  7  months. 

{  3  are  described  simply  as  "  cured." 

Ot  a.  cases  of  .'  cure"      .    \\Z  ^tSdofthroiiratio.." 

C.1  lived  for  4  years  after  the  enterotomy. 

€oIotoiiiy.— This  procedure  is  applicable  only 
to  obstructions  in  the  colon,  and  consists  in  estab- 
lishing an  artificial  anus  in  the  gut  above  the  point 
of  occlusion.  There  are  two  forms  of  colotomy  : 
lumbar    colotomy,    commonly    known    as    Amussat's 


Chap.  XXV,]  Z//^  Treatment:  Colotomv. 


471 


operation,  and  inguinal  colotomy,  usually  referred  to 
as  Littre's  operation.  In  the  former,  the  ascending 
or  descending  colon,  as  the  case  might  be,  is  reached 
through  an  incision  made  in  the  loin.  An  opening  is 
made  in  the  gut  behind  the  peritoneum,  and  the 
serous  cavity  is  not  opened.  In  the  latter,  the  colon 
is  reached  by  an  incision  in  the  iliac  region  placed  a 
little  above  Poupart's  ligament  and  external  to  the 
epigastric  artery.  The  cavity  of  the  peritoneum  is 
opened  and  an  incision  is  made  into  the  gut  through 
its  peritoneal  covering.  The  two  modes  of  operating, 
therefore,  differ  considerably.  From  Erckelen's  "^  very 
extensive  statistics  of  colotomy,  an  abstract  of  which 
is  appeDded,  it  will  be  seen  that  Amussat's  operation 
is  the  safer  of  the  two,  there  being  a  difference  of 
nearly  ten  per  cent,  between  the  mortality  after  the 
two  procedures. 

Lumbar  Colotomy  (Erckelen's  Statistics). 

ToiaX  operations,  262  =  Amussat's  method,  165 ;  Littre's,  84 ;  Method 
unknown,  13. 

Indications. — Cancer,  100  cases  ;  fistulse,  16  caises  ;  atresia,  44  cases  ; 
stricture,  49  cases ;  obstruction,  43  cases. 

Age. 


Age^. 

Cases. 

Recoveries:. 

Deaths. 

1  to  10  years. 

47 

21 

25 

1  result  unknown. 

10  to  20      „ 

5 

4 

1 

20  to  30      „ 

30 

21 

9 

•60  tu  -iO      „ 

27 

12 

15 

40  to  £0      „ 

40 

26 

14 

50  to  60      „ 

38 

23 

15 

60  to  70      „ 

27 

20 

7 

70  to  80      „ 

4 

1 

3 

UurecordeJ. 

44 

23 

20 

1  result  unknown 

Sea;.— Male,  128  ;  Female,  96 ;  Unknown,  38. 
Death  took  place : 

In  first  week  in  70  cases,  including  43  on  first  or  second  day. 
In  second  week  in  15  cases. 
In  third  week  in  8  cases. 
Time  not  recorded,  15  cases. 

*  Arcliiv  f .  Klin.  Chir.  Langenbeck,  1879,  page  41. 


472  Intestinal  Obstruction.       ichap.  xxv. 

In  tlie  total  of  262  tlie  operation  ended : 

Favourably  in  152  (58  i  per  cent.),  i.e.  the  patient  survived  21 

days. 
Unfavourably  in  108   (54-2  per  cent.),  i.e.  the  patient    did  not 
survive  21  days. 

Eesult  unknown  in  2. 

Of  the  165  by  Amussat's  method: 

101  recovered 63*0  i)er  cent. 

63  died 38-J-        „ 

1  result  unrecorded. 

Of  the  84  by  Littre's  method  : 

44  recovered 52*4  per  cent, 

39  died  46-4        „ 

1  result  unrecorded. 

Of  the  13  cases  by  unrecorded  methods,  7  recovered  and  6  died. 

Cavcmoma., 
110  cases        .        .  68  ended  favourably  42  unfavourably. 

813  by  Amussat's  .  52  (639  per  cent.)  ended  favourably  31  ,, 

23  by  Littre's       .  14  (61-0        „         )    „  „  9  „ 

4  by  unknown  methods        ...        1  died,  3  recovered. 

10  cases        .        .  13  (81'0  per  cent.)  ended  favourably    3  unfavourably. 

44  cases        .        .  20  (452  per  cent.)  ended  favourably  24  unfavourably. 

49  cases        .        .  29  (59*2  per  cent.)  ended  favourably  20  unfavourably. 
38  by  Amussat's .  25  ,,  ,,  13  „ 

9  by  Littre's      .3  „  „  6  „ 

2  result  unrecorded. 

Obstrwclioti. 
43  cases        .        .  22  ended  favourably  21  unfavourably. 

20  by  Amussat's .  10  „  ,,  10  ,. 

18  by  Littre's      .  10  „  „  8 

5  result  unrecorded. 

In  the  lumbar  operation  the  gut  may  be  more 
readily  and  more  safely  reached  ui)on  the  right  than 
upon  the  left  side.  The  descending  colon  is  less 
movable  than  the  ascending,  and  has  also  a  more  ex- 
tensive non-peritoneal  surface.  A  meso-colon  is  more 
often  found  upon  the  right  than  upon  the  left  side, 
and  the  presence  of  this  condition  would  involve  an 
opening  into  the  sac  of  the  peritoneum.  Moreover,  in 
malformations  of  the  colon  the  abnormal  condition  is 
more  frecjuently  found  upon  the  right  than  upon  the 
left  side.     It   may    be    possible    to    attempt   a   right 


Chap.  XXV.]   The  Treatment :  Colotomy.  473 

lumbar  colotomy  and  find  no  colon  at  all  in  the  usual 
position.  Indeed,  the  ascending  colon  may  be  entirely 
absent.  The  question  of  a  right  versus  a  left  lumbar 
colotomy  will  be  discussed  further  when  dealing  witli 
the  treatment  of  obstructions  in  the  colon. 

In  Littre's  procedure  the  incision  may  be  made 
either  upon  the  left  or  the  right  side.  In  the  former 
case  the  sigmoid  flexure  is  the  part  opened  ;  in  the 
latter  case  the  csecum  becomes  the  seat  of  the  artificial 
anus.  The  left  operation  is  limited  to  cases  of  stric- 
ture of  the  rectum  or  terminal  part  of  the  sigmoid 
flexure.  The  right  operation  is  the  one  concerned  in 
the  present  subject. 

There  are  many  excellent  reasons  for  selecting  the 
caecum  in  these  cases.  It  is  usually  much  distended 
and  very  prominent.  In  long-standing  cases  it  is  a 
part  much  in  need  of  early  relief,  since  the  great 
strain  of  the  accumulation  falls  upon  its  walls,  and  its 
mucous  membrane  not  infrequently  becomes  ulcerated. 
Perforation  by  one  of  these  ulcers  is  a  common  cause 
of  death  in  stenoses  of  the  colon.  I  could  refer  to 
several  instances  where  this  perforation  has  taken 
place  after  a  colotomy  performed  on  another  part  of 
the  colon,  and  where  it  may  be  said  that  the  caecum 
has  been  relieved  too  late.  It  must  be  remem- 
bered, however,  that  the  caecum  is  liable  to  many 
abnormalities  due  to  congenital  defect,  and  that 
the  right  iliac  region  may  be  opened  up  and 
no  trace  of  the  ct^cum  found.  In  both  forms  of 
colotomy  much  distress  is  often  occasioned  by  the 
accumulation  of  faeces  that  usually  exists  between  the 
artificial  anus  and  the  occluded  part.  The  greater 
the  distance  between  these  two  points  the  more 
serious  is  the  trouble  likely  to  be."^  As  soon  after  the 
operation  as  the  condition  of  the  wound  will  permit, 

*  See  illustrative  case  by  Mr.  Bryant;  Lancet,  vol.  i.,  1878, 
page  743. 


474  Intestinal  Obstruction.       [Chap,  xxv 

steps  should  be  taken  to  relieve  the  gut  of  this  ob- 
struction. 

In  both  Amussat's  and  Littre's  operation,  the  pro- 
cedure may  be  divided  into  two  parts,  when  the 
demands  of  the  case  are  not  urgent,  and  the  first  and 
more  important  part  of  the  operation  may  be  per- 
formed under  antiseptic  precautions.  In  this  first  step 
the  gut  is  exposed  and  stitched  to  the  edges  of  the 
wound  by  sutures  that  do  not  pass  entirely  through 
the  thickness  of  the  intestinal  wall.  A  few  days  are 
allowed  for  the  bowel  to  contract  firm  adhesions  to  the 
margins  of  the  incision.  When  all  the  parts  are 
firmly  sealed  with  lymph  the  operation  is  completed 
by  opening  the  intestine.  In  Littre's  procedure  this 
plan  makes  the  opening  of  the  peritoneum  a 
comparatively  harmless  proceeding,  and  renders  the 
chance  of  escape  of  faecal  matter  into  the  serous 
cavity  practically  impossible.  In  the  lumbar  opera- 
tion the  plan  is  equally  valuable.  It  minimises  the 
evils  that  may  follow  from  an  accidental  wound  of 
the  peritoneum,  and  tends,  moreover,  to  prevent  suppu- 
ration in  the  loose  subserous  tissue  that  is  opened  up 
when  the  gut  is  exposed.  I  have  seen  a  case  of  left 
lumbar  colotomy  where  this  suppuration  had  extended 
do^\ai  along  the  colon  to  the  rectum  and  had  ulti- 
mately caused  death. 

After  a  lumbar  colotomy  has  been  f>erformed  a 
gi'eat  deal  of  inconvenience  is  often  experienced  by  the 
patient  owing  to  the  accumulation  of  faecal  matter 
between  the  artificial  anus  and  the  seat  of  obstruction. 
Madelung  has  recently  proposed  "^  a  modification  of 
the  operation  which  should  prevent  this  complicatioiL 
Madelung  does  not  content  himself  with  merely  open- 
ing the  colon,  but  he  cuts  the  bowel  entirely  across. 
He  stitches  the  upper  end  of  the  divided  intestine  to 

*  Deutschen  Gesellsliaft  fur  Chirurgie,  April,  1884  ;  Central, 
f.  Chir.,  No.  23,  1884. 


Chap.  XXV.]   The  Treatment :  Colotomv.  475 

the  edges  of  the  abdominal  wound,  and  so  establishes 
an  artificial  anus.  He  then  empties  the  lower  seg- 
ment of  the  bowel  of  its  contents,  and  having  entirely 
closed  its  divided  end  reduces  it  into  the  abdominal 
cavity  (behind  the  peritoneum),  and  closes  the  skin 
incision  over  it.  This  procedure  is  only  proposed  for 
cancer  of  the  rectum  or  of  the  sigmoid  flexure.  It 
could  be  applied,  however,  to  any  form  of  obstniction 
involving  these  parts  which  may  be  considered  to  be 
quite  beyond  relief  by  further  treatment.  The  measure 
would  prevent  the  evils  arising  from  the  irritation  of 
the  cancerous  surface  by  faecal  matter,  and  should 
greatly  minimise  the  tendency  to  prolapse  of  the  gut 
at  the  seat  of  the  operation. 

Colotomy  has  been  performed  for  all  varieties  of 
obstruction  of  the  colon,  but  especially  for  such  as  are 
of  a  chronic  character.  The  selection  of  the  place  of 
operation  depends,  of  course,  upon  the  correctness  of 
the  diagnosis ;  and  in  many  cases  where  the  diagnosis 
has  been  in  error  a  useless  operation  has  been  per- 
formed. Thus,  in  a  case  of  volvulus  of  the  ascending 
colon  and  c£ecum,  left  lumbar  colotomy  was  performed. 
By  chance  the  extreme  point  of  the  greatly  distended 
and  displaced  ascending  colon  was  opened,  but  without 
relief  to  the  patient."^ 

In  many  cases  the  artificial  anus  has  been  made 
below  the  seat  of  the  obstruction  in  the  colon  ;  f  and 
the  descending  colon  has  even  been  opened  for  an  oc- 
clusion that  involved  the  small  intestine.  J 

Mr.  Lockwood  §  has  given  an  account  of  two  cases 
of  attempted  lumbar  colotomy,  in  neither  of  which  was 
the  colon  found,  owing  to  a  congenital  deformity  of 
the  large  intestine. 

*Path.  Soc.  Trans.,  vol.  ii.,  page  222. 
f  For  instances  see  Dr.  Fagge's  Monograph. 
J  Path.  Soc.  Trans.,  vol.  xii.,  page  111. 

§  St.  Bart. '3  Hosi).  Reports,  vol.  xix.  See  also  A  Manual  of 
Surgical  Anatomy,  by  the  author,  page  314. 


47^  Intestinal  Obstruction.       ichap.  xxv 

Resection  of  intestine.— In  tliis  operation  a 
diseased  portion  of  intestine  is  entirely  cut  away  and 
removed  from  the  body.  The  term  enterectomy  is 
applied  to  the  procedure  when  it  involves  the  small 
intestine,  the  term  colectomy  when  it  concerns  the 
colon. 

Enterectomy  may  be  performed  for  the  following 
conditions  :  1.  Strictures  of  the  small  intestine  both 
simple  and  epitheliomatous.  2.  Occlusion  of  the 
bowel  by  adhesion,  and  matting  of  the  coils  of  such  a 
character  that  the  deviation  of  the  gut  cannot  be  cor- 
rected. 3.  Obstruction  by  neoplasms  other  than 
epitheliomata.  4.  Gangrene  of  the  bowel  due  to  any 
of  the  manifold  forms  of  strangulation.  5.  Irredu- 
cible intussusceptions.  6.  For  the  closure  of  faecal 
fistulse  situated  in  the  small  intestine. 

The  great  bulk  of  the  ojjerations  of  enterectomy 
have,  up  to  the  present  time,  been  performed  for  the 
removal  of  gangrenous  bowel  following  strangulated 
hernia,  and  for  the  closure  of  fascal  fistuloe. 

It  will  be  convenient  to  consider,  in  the  first  place, 
the  data  upon  which  the  value  of  the  procedure  is  based 
in  the  various  conditions  above  named.  1.  In  cases 
of  stricture  of  the  small  intestine,  the  patient  may  be 
relieved,  and  may  be  saved  from  immediate  death  from 
obstruction,  by  an  operation  other  than  the  one  under 
notice  ;  but  by  the  present  procedure  alone  can  the 
patient  be  cured.  Enterotomy  may  give  relief,  but 
enterectomy  is  the  only  means  of  cure.  Enterotomy 
leaves  the  patient  with  the  obstruction  still  untreated, 
and  it  renders,  moreover,  an  artificial  anus  an  absolute 
necessity.  If  this  fistula  be  in  the  lower  ileum,  the 
patient's  life  may  be  indefinitely  prolonged  ;  but  if  it 
be  situated  in  the  upper  parts  of  the  lesser  bowel, 
then  a  more  or  less  rapid  death  from  marasmus  is  in- 
evitable. In  addition  to  this,  and  as  a  matter  of 
less  moment,  the  artificial  anus  involves  a  grave  and 


c^inp.  XXV.]  The  Treatment :  Resection.  477 

abiding  source  of  inconvenience,  and  leaves  the 
patient  exposed  to  the  troubles  that  occasionally  arise 
from  the  presence  of  retained  feecal  matter  in  the  bowel 
below  the  seat  of  the  obstruction.  By  means  of  enter- 
ectomy  the  cause  of  the  trouble  may  be  removed^  and 
the  integrity  of  the  intestinal  canal  restored. 

Tf  the  stricture  be  carcinomatous,  the  condition  is 
still  more  serious.  Enterotomy  may  relieve  the  patient 
of  obstruction  symptoms,  but  it  leaves  untouched 
within  his  body  a  growth  that  will  assuredly  increase, 
and  will  at  no  distant  time  inevitably  lead  to  death. 
It  happens  that  the  form  of  cancer  that  is  usual  in 
the  intestine  is  a  form  that  is  peculiarly  well  adapted 
for  treatment  by  excision,  and  by  enterectomy  not 
only  may  death  from  obstruction  be  averted,  but  the 
patient  may  be  relieved  of  a  fatal  malady. 

2  and  3.  To  the  conditions  that  fall  under  these  head- 
ings the  same  remarks  apply  as  have  been  used  in 
speaking  of  enterectomy  in  simple  stricture.  In  cases 
of  obstruction  by  the  matting  together  of  many  coils, 
the  propriety  of  the  operation  must  be  influenced  by 
the  length  of  intestine  involved.  In  the  light,  how- 
ever, of  Koeberle's  very  successful  case,  where  over 
two  yards  of  the  lesser  bowel  were  removed,"^  it  is 
evident  that  liberal  views  may  be  entertained  upon 
this  point. 

4.  The  value  of  resection  in  instances  of  gangrene 
is  obvious.  To  liberate  a  piece  of  bowel  that  is  stran- 
gulated by  a  band  and  gangrenous  in  consequence,  and 
then  to  leave  that  loop  in  the  abdomen,  is  to  undertake 
an  operation  that  had  better  have  been  left  alone.  It 
would  appear  obvious  also  that  it  would  be  better  to 
resect  the  damaged  loop  than  to  simply  draw  it  out 
of  the  abdominal  wound,  and  allow  it  to  slough  off,  if  for 
no  other  reason  than  that  during  the  process  of  separa- 
tion the  intestinal  obstruction  would  be  maintained. 

*  Bull,  et  Mem.  de  la  Soc.  de  Chir.  de  Paris,  1881,  page  99. 


478  Intestinal  Obstruction.     '[Chap.  xxv. 

5.  If,  in  a  case  of  intussusception,  non-operative 
treatment  has  failed,  and  the  abdomen  has  been  opened 
and  the  invagination  found^to  be  irreducible,  the  opera- 
tion of  enterotomy  affords  the  only  means  of  relief 
if  resection  be  not  performed.  Enterotomy,  however, 
performed  under  these  circumstances,  offers  even  less 
jjrospects  of  success  than  it  does  in  cases  of  simple 
stricture.  Not  only  does  the  obstruction  remain 
unrelieved,  but  a  portion  of  gut  is  left  in  the  abdomi- 
nal cavity  that  may  cause  fatal  mischief.  The 
unreduced  intussusception  may,  in  spite  of  the 
artificial  anus  above  it,  become  gangrenous  ;  or  its  walls 
may  ulcerate ;  or  the  imflammation  existing  in  its 
tissues  may  lead  to  a  fatal  peritonitis.  It  is  only 
by  an  excision  of  the  involved  segment  that  these  evils 
can  be  obviated. 

6.  Resection  for  faecal  fistula  has  little  direct  con- 
cern with  the  present  subject.  Enterectomy  performed 
for  the  cure  of  artificial  anus  is  of  the  nature  of 
a  plastic  operation.  The  piece  of  gut  the  seat  of  the 
fistula  is  excised,  and  the  two  divided  ends  having 
been  united  by  suture,  the  bowel,  whose  integrity 
has  thus  been  restored,  is  reduced  into  the  abdomen, 
and  the  wound  in  the  parietes  is  closed.  A  large 
number  of  resections  have  been  performed  under  these 
circumstances,  and  the  results  obtained  are  of  consider- 
able moment  in  estimating  the  value  of  certain  details 
in  resection  procedures  which  are  more  fully  dealt 
with  below. 

Colectomy  has  been  so  far  limited  to  cases  of  stric- 
ture chiefly  of  an  epitheliomatous  character,  and  to  arti- 
ficial anus.  The  operation  could,  however,  be  adopted 
for  other  conditions  of  disease  in  the  large  intestine 
that  are  of  like  character  with  those  just  named  in 
connection  with  the  lesser  bowel.  Colectomy  cannot 
be  considered  to  present  the  same  claims  that  may 
be  advanced  on  behalf  of  the  operation  as  applied  to 


Chap.  XXV.]  The  Treatment :  Resection.  479 

the  small  intestine.  An  artificial  anus  in  the  colon  is 
hy  no  ni(!ans  so  inconvenient  nor  so  detrimental  to 
health  as  is  a  fsecal  fistula  in  the  lesser  bowel,  and 
colotomy  as  a  moans  of  relief  in  colic  stenoses  must 
be  regarded  as  a  very  successful  operation.  Colotomy 
of  course  leaves  the  cause  of  the  obstruction  untouched, 
and  renders  a  permanent  artificial  anus  necessary, 
whereas  colectomy  removes  the  disease  entirely,  and 
allows  the  normal  lumen  of  the  bowel  to  be  restored. 
In  cases  of  simple  stricture,  colotomy,  as  compared  with 
resection,  concerns  mainly  the  convenience  of  the 
patient,  and  not  a  question  of  life  and  death.  Such 
being  the  case,  the  mortality  of  the  two  operations 
should  be  as  nearly  as  possible  upon  a  par,  and  it  must 
be  owned  that  at  present  this  position  cannot  be 
claimed  for  the  resection  operation.  In  instances  of 
epithelioma  of  the  colon,  however,  the  claims  of 
colectomy  can  be  advanced  with  much  greater  point. 
In  such  cases,  the  establishment  of  an  artificial 
anus  but  relieves  the  patient  for  awhile,  and  leaves 
untouched  a  malignant  growth  that  by  means  of 
colectomy  may  be  entirely  and  freely  removed. 

Speaking  generally  of  the  operation  of  resection  of 
intestine,  it  should  be  noted  that  the  procedure  involves 
no  new  surgical  principle,  and  embodies  no  revolution 
in  treatment.  It  merely  implies  the  tardy  application 
to  abdominal  disorders  of  modes  of  cure  that  have  for 
centuries  been  applied  to  other  parts  of  the  body. 
In  principle  it  simply  involves  the  removal  of  diseased 
parts  that  cannot  be  treated  by  other  means,  the 
excision  of  malignant  cjrowths  that  cannot  be  got  rid 
of  by  milder  measures,  the  separating  of  gangrenous 
tissues  from  contact  with  the  living  body  that  cannot 
be  so  separated  by  natural  means. 

The  TYiodus  operandi. — There  are  two  different 
methods  of  resecting  the  intestine.  In  the  one,  the 
diseased  segment  is  excised ;  the  divided  ends  of  the 


480  Intestinal  Obstruction.      [chap. xxv. 

bowel  are  then  carefully  united  by  many  points  of 
suture;  the  parts  so  adjusted  are  reduced  into  the 
abdominal  cavity,  and  the  wound  in  the  parietes  is 
closed.  In  the  other,  after  the  necessary  portion  has 
been  removed,  the  divided  ends  are  stitched  to  the 
edges  of  the  skin  incision,  and  an  artificial  anus  is 
established.  After  a  varying  interval  of  time,  a  second 
resection  operation  is  performed  upon  the  portion  of 
intestine  involved  in  the  faecal  fistula,  the  lumen  of 
the  tube  is  restored  by  suturing  the  two  ends,  and  the 
parietal  wound  is  closed.  The  details  of  these  two 
procedures  may  now  be  described,  so  far  as  they  refer 
in  the  first  instance  to  the  small  intestine. 

1.  A  laparotomy  is  performed,  and  preferably  by 
an  incision  in  the  middle  line.  The  advantages  of  a 
median  incision  have  been  referred  to  in  speaking  of 
laparotomy.  Through  such  a  cut,  any  part  of  the 
small  intestine  may  be  reached,  and  the  surgeon  is 
rendered  independent  of  a  precise  knowledge  of  the 
locality  of  the  obstruction.  If  any  certain  evidence 
exists  to  point  to  the  precise  seat  of  the  lesion, 
then  the  incision  may  be  made  over  that  spot,  or  over 
the  semi-lunar  line  that  is  nearest  to  it.  The  segment 
of  bowel  to  be  excised  is  then  drawn  out  of  the 
abdominal  wound.  Before  proceeding  further,  steps 
should  be  taken  to  prevent  any  blood  or  faecal  matter 
set  free  by  the  operation  from  entering  the  peritoneal 
cavity.  This  occurrence  can  be  prevented  either  by 
closing  the  abdominal  wound  by  sutures  as  far  as  the 
protruding  loop  of  bowel  will  allow,  or  by  plugging  that 
wound  carefully  with  warm  carbolised  sjDonges.  The 
next  step  is  to  occlude  the  bowel,  both  above  and  below 
the  part  that  is  to  be  excised.  For  this  purpose,  some 
surgeons  content  themselves  with  the  pressure  that 
can  be  exercised  by  the  fingers  of  an  assistant,  while 
others  secure  the  bowel  by  elastic  or  silk  ligatures. 
Both    of  these   methods   are    open   to   objection.     In 


Chap.  XXV.]  The  Treatment :  Resection. 


481 


adopting  the  first  plan,  it  will  be  found  that  the 
hands  of  the  assistant  will  probably  become  tired  out 
before  the  operation  (which  must  always  be  of  long 
duration)  is  completed.  Moreover,  if  the  assistant 
has  to  relax  his  hold  at  any  time  to  accommodate 
himself  to  the  manoeuvres  of  the  surgeon,  the  intestinal 
contents  may  escape,  and  in  any  case  two  additional 
hands  in  the  precincts  of  the  wound  greatly  narrow 
the  area  of  the  operation.  Ligatures  of  all  kinds  are 
objectionable   on  account  of  the  damage  they    must 


Pig.  58.— Treves'  Clamp  for  Enterectomy  or  Colectomy. 

almost  of  necessity  inflict  upon  the  delicate  walls  of 
the  intestine.  It  is  evident  that  assistance  must  be 
sought  from  some  species  of  clamp.  A  clamp  that  I 
have  devised  for  this  purpose,  and  the  use  of  which 
I  have  fully  described  elsewhere,"^  seems  to  meet,  I 
venture  to  believe,  some  of  the  chief  requirements 
demanded  of  such  an  instrument  (Fig.  58).  This 
clamp  is  made  in  two  parts,  one  for  the  upper  and 
one  for  the  lower  end  of  the  intestine.  These  two 
portions   are  quite  separate,  are  readily  applied,  and 

*  Mecl.-Chir.  Trans.,  vol.  Ixvi.,  page  55. 
F  F — 12 


482 


Intestinal  Obstruction.      [Chap. xxv. 


occupy  very  little  room.  The  compressing  surfaces 
are  covered  with  indiarubber,  and  are  brought 
together  by  means  of  screws.  When  the  gut  has  been 
resected,  and  the  two  di^dded  ends  require  to  be 
carefully  approximated  in  order  that  the  sutures  may 
be  introduced,  the  two  portions  of  the  clamp  are  fixed 
by  means  of  connecting  rods,  so  that  a  rigid  frame- 
work is  formed,  the  length  of  which  can  be  regulated 
by  a  slight  and  easy  adjustment  of  these  little  rods. 


Fig.  59.— Bishop's  Clamp  for  Eutereitomy. 
A  the  claraps  ;  b,  the  sprcws  l)v  means  nf  wbicb  the  blades  of  the  clamps  are  ap- 
proximated ;  c,  the  acrcw  by  means  of  which  the  clamps  are  adjusted. 

A  clamp  of  a  more  ingenious  construction  has 
been  introduced  by  Mr.  Bishop,  of  Manchester.*  In 
this  instrument  the  two  portions  of  the  clamp  are 
connected  by  means  of  a  sccew,  by  one  movement  of 
which  they  can  be  approximated,  and  by  another 
moved  apart  (Fig.  59).  One  slight  disadvantage  in 
Mr.  BishojVs  instrument  is  its  size  and  weight,  and 
the  inconvenient  dimensions  and  position  of  the  con- 
necting screw.  It  is,  however,  much  more  readily 
applied  than  is  the  clamp  to  which  I  have  just  referred. 
The  clamps  having  been  applied,  the  diseased 
*  BriU  MuL  Journ.,  Nov.  3,  1883. 


Chap.  XXV.]  The  Treatment:  Resection.  483 

segment  of  gut  between  tliem  is  excised  with  scissors, 
a  certain  portion  of  sound  intestine  being  allowed  to 
intervene  between  the  proposed  line  of  sutures  in  each 
case  and  the  line  of  compression  by  the  clamps.  The 
bowel  should  be  divided  upon  a  sponge,  so  that  nothing 
may  escape  into  the  peritoneal  cavity ;  and  if  the  dis- 
eased segment  has  been  well  emptied  of  its  contents 
before  the  clamps  are  applied,  the  amount  of  matter 
that  could  escape  should  be  slight.  Attention  must 
now  be  turned  to  the  mesentery,  from  which  a 
triangular  piece  must  be  cut,  the  base  of  the  tiiangle 
corresponding  to  that  part  of  the  membrane  that  is 
attached  to  the  resected  segment  of  bowel.  When  a 
large  portion  of  intestine  has  to  be  removed,  the  apex 
of  this  triangular  gap  in  the  mesentery  may  have  to 
be  carried  to  its  very  root. 

The  mesenteric  vessels  are  usually  distinct, 
especially  as  in  cases  demanding  resection  they  are 
apt  to  be  engorged.  This  being  the  case,  the  most 
conspicuous  of  them  can  be  secured  and  ligatured 
before  the  membrane  is  cut.  In  resection  experi- 
ments performed  upon  living  animals,  I  have  never 
found  any  difficulty  in  dealing  with  these  vessels.* 
Having  removed  both  the  intestine  and  its  mesentery, 
the  two  cut  edges  of  the  latter  should  be  carefully 
approximated  by  sutures.  I  hold  that  the  resection 
of  a  triangular  piece  of  the  mesentery  and  the  sub- 
sequent closure  of  the  gap  so  made  by  sutures  is  of 
vital  importance.  If  the  membrane  be  not  so  treated, 
the  gut,  when  united  and  reduced,  is  almost  certain  to 
become  occluded  by  kinking  at  the  suture  line,  a 
catastrophe  that  has  occurred  in  some  of  the  recorded 
cases  in  the  human  subject.  The  mesentery  should, 
if  possible,  not  be  divided  quite  up  to  the  line  of 
division  in  the  bowel,  in  order  that  the  nutrition  of 

*  It  is  necessary  to  state  that  none  of  the  vivisection  experi- 
ments alluded  to  in  this  work  were  performed  in  this  country. 


484  Intestinal  Obstruction.      [Chap. xxv. 

the  cut  edge  of  the  intestine  be  not  interfered  with 
more  than  is  possible.  It  is  obvious  that  the  sound 
and  rapid  healing  of  the  intestinal  wound  will  depend 
upon  the  nutritive  activity  of  the  divided  ends,  and  it 
is  fortunate  that  the  anatomical  arrangements  of  the 
vessels,  both  in  the  mesentery  and  in  the  walls  of  the 
bowel,  prevent  this  activity  from  being  greatly  inter- 
fered with  in  the  resection  operations. 

In  cases  of  epithelioma  of  the  gut,  the  excision  of 
a  large  triangular  piece  of  the  mesentery  will  usually 
permit,  at  the  same  time,  of  the  removal  of  any  en- 
larged glands  in  the  immediate  vicinity  of  the 
disease. 

The  two  divided  ends  of  intestine  are  now  to  be 
brought  into  close  contact  with  one  another,  and  if 
either  of  the  two  clamps  described  above  are  used, 
this  object  can  be  readily  effected.  The  sutures  have 
next  to  be  introduced.  They  should  be  introduced  in 
a  double  row,  the  first  series  bringing  the  edges  of  the 
mucous  membrane  together ;  the  second  or  external 
series  uniting  the  serous  surfaces  of  the  bowel.  When 
the  intestine  is  divided,  the  muscular  coat  retracts, 
carrying  with  it  the  serous  coat.  By  this  contraction 
the  mucous  layer  is  freely  exposed,  and  the  introduc- 
tion of  the  inner  row  of  sutures  is  a  matter  of  no 
difficulty  (Fig.  60,  a). 

With  regard  to  the  outer  line  of  sutures,  the  most 
convenient  stitch  is  that  known  as  Lembert's.  It  is 
readily  applied,  and  brings  the  serous  surfaces  into 
close  contact.  It  is  well  known  that  the  union  of  the 
divided  ends  of  the  intestine  will  be  first  effected  and 
chiefly  maintained  by  the  fusion  of  tlie  serous  siirfaces. 
This  union  is,  however,  slight  in  character,  and  not 
sufficiently  substantial  to  withstand  much  strain. 
The  use,  therefore,  of  the  inner  row  of  sutures  is  most 
important :  they  serve  to  strengthen  the  union,  while 
they  help  greatly  to  protect  the  healing  wound  on 


Chap.  XXV,]  The  Trea  tment  :  Resection. 


485 


the  serous  surface  from  contact  with  the  septic 
matters  within  the  lumen  of .  the  bowel. 

By  means  of  Gussenbauer's  stitch  the  mucous  and 
serous  layers  of  the  bowel  may  be  brought  together 
by  one  suture.  This  mode  of  using  the  needle  is, 
however,  not  to  be  advised.  It  is  complicated,  and 
does  not  save  any  time  in  the  operation  (Fig.  GO,  b). 

The  needle  used  in  the  process  of  suturing  shoidd 
be  very  small,  should  be  so  curved  as  to  represent 


A  B 

Fig.  60.— A,  Czeruy-Lembert  sixture.    B,  Gussenbaner's  suture. 
((,  iiuK'oui^  coat  ;  h,  iiuiscular  coat ;  c,  serous  coat. 

half  a  circle,  should  be  perfectly  round  on  section,  and 
of  the  same  thickness  from  the  "eye"  to  within  a 
short  distance  of  the  point.  The  best  material  for 
the  stitches  is  the  finest  Chinese  twist.  It  is  much 
more  easy  to  manipulate  than  catgut  or  horsehair  or 
silk-worm  gut,  or  even  than  fine  silk. 

In  all,  some  forty  points  of  suture  are  required, 
fifteen  for  the  inner  row,  and  twenty -five  for  the  outer. 
The  most  difficult  sutures  to  introduce  are  those 
applied  at  the  line  of  the  attachment  of  the  mesen- 
tery j  and  it  is  significant  that  in  cases  of  yielding  of 


486  Intestinal  Obstruction.      [Chap.  xxv. 

the  sutures  the  occurrence  has  been  most  often  noted 
at  this  spot. 

The  two  divided  ends  of  intestine  that  have  to  be 
united  are,  of  course,  limp  and  non-resistant,  and 
render  the  introduction  of  the  sutures  a  matter  of 
some  difficulty.  The  need  is  felt  of  some  firm  sub- 
stance upon  which  the  bowel  may  rest  while  the 
stitches  are  being  introduced.  To  fulfil  this  object 
some  surgeons  have  proposed  the  introduction  into  the 
ends  of  the  divided  intestine  of  a  cylinder  of  gelatine, 
wdiich  would,  after  the  operation,  be  dissolved  and 
disappear.  Hohenliausen  has  made  use  of  a  cylinder 
or  plug  of  dough,*  and  ISTeuber  of  a  tube  of  decalcified 
bone.f  These  various  substances,  however,  are  very 
apt  to  act  as  foreign  bodies,  and  to  cause  an  undesir- 
able obstruction  at  the  suture  line.  To  meet  the 
purpose  sought  by  the  use  of  these  plugs  I  have 
employed  a  thin  indiarubber  bag  of  sausage  shape. 
This  bag  is  introduced  into  the  two  approximated 
ends  of  the  intestine  in  a  flaccid  state,  and  is  then 
inflated  in  situ.  It  forms  a  firm  basis  for  the  intro- 
duction of  the  sutures,  and  is  in  no  danger  of  being 
pricked  if  the  stitches  are  properly  introduced. 
Before  the  last  sutures  are  inserted,  the  air  is 
allowed  to  escape  from  the  bag,  which  is  then  with- 
drawn. "When  empty,  the  bag  is  so  thin  that  it  can 
be  drawn  through  a  hole  that  would  not  admit  the  tip 
of  the  little  finger.  I  have  used  this  bag  in  vivisec- 
tion experiments  and  on  the  human  subject,  |  l)ut 
have  now  discarded  it  as  unnecessary. 

After  the  divided  ends  of  the  l)owel  have  been 
united,  the  clamps  are  removed,  and  the  loop  having 
been  replaced  into  the  abdominal  cavity,  the  wound  in 
the  parietes  is  closed. 

*  Deutsche  med.  Wochens,  Sept.  -5,  1883. 
t  Central,  fur  Chirurg.,  No,  23,  1884. 
JMed.-Chir.  Trans,,  vol.  lx\-i.,  page  55. 


Chap.  XXV.]  The  Treatment :  Resection.  487 

Schede*  has  suggested  that  the  sutured  segment 
should  not  be  at  once  reduced,  but  should  be  fixed 
outside  the  peritoneum.  This  modification  has  for  its 
object  the  prevention  of  extravasation  at  the  suture 
line.  The  method,  however,  has  little  to  commend  it, 
and  is  open  to  all  the  objections  that  have  been  urged 
against  the  extra-peritoneal  treatment  of  the  pedicle 
in  ovariotomy. 

In  the  operation  upon  the  colon,  the  proceeding  is 
practically  identical  with  that  just  described.  In 
dealing  with  the  colon,  however,  the  great  difficulty 
is  the  position  of  the  incision  through  the  abdominal 
parietes.  There  is  no  doubt  that  in  attempting  to 
resect  a  portion  of  the  ascending  or  descending  colon, 
there  is  no  better  incision  than  that  used  in  lumbar 
colotomy.  This  incision  affords  plenty  of  room  for 
the  operation,  and  it  is  surprising  how  much  of  the 
vertical  part  of  the  colon,  and  especially  of  the  de- 
scending colon,  can  be  drawn  out  and  exposed  in  a 
wound  in  the  loin.  When,  therefore,  the  seat  of  the 
obstruction  is  diagnosed  for  certain  to  be  in  either 
the  ascending  or  descending  colon,  the  usual  incision 
for  colotomy  should  be  selected  for  the  resection 
operation. 

If  there  should  be  distinct  evidence  to  localise  the 
disease  in  the  transverse  colon  or  sigmoid  flexure,  then 
the  preliminary  incision  should  be  made  through  the 
parietes,  directly  over  the  involved  part  of  the  intes- 
tine. When,  however,  any  doubt  exists  as  to  the 
situation  of  the  obstruction,  it  is  safer  to  open  the 
abdomen  in  the  middle  line.  This  incision  may  be 
made  for  diagnostic  purposes,  and  a  second  incision 
then  made  over  the  seat  of  the  disease  as  soon  as  it 
has  been  ascertained.  It  is  far  better,  however,  to 
perform  the  resection  through  the  median  wound 
when  possible.  When  impossible,  as  it  has  been 
*  Quoted  by  Reichel. 


483  Intestinal  Obstruction.        [Chap.xxv. 

shown  to  be  in  several  cases,  the  median  incision 
should  be  closed,  and  a  second  cut  made  over  the  seat 
of  the  obstruction.  In  some  cases  where  a  median 
incision  has  been  made,  and  the  disease  found  to  be 
in  one  or  other  loin,  the  original  wound  has  been  con- 
tinued into  the  loin  by  means  of  a  transverse  cut.* 
This  procedure  is  certainly  to  be  condemned.  Indeed, 
so  far  as  the  reports  of  cases  at  present  go,  this  com- 
plicated wound  appears  to  have  been  always  attended 
by  unfortunate  results. 

In  more  than  one  instance  the  parts  resected 
were  so  extensive,  and  the  involved  gut  so  fixed,  that 
it  was  found  impossible  to  unite  the  two  ends  of  the 
divided  bowel,  and  a  permanent  fsecal  fistula  was 
thtrefoixj  inevitable,  f 

The  most  extensive  statistics  of  this  operation  are 
those  collected  by  Keichel.  \  He  has  brought  together 
121  reported  ca,ses  of  gut  resection,  with  subsequent 
suturing  of  the  divided  ends.  Out  of  this  number 
58  died,  58  are  described  as  cured,  and  5  recovered 
with  a  permanent  faecal  fistula. 

r  21  recovered. 
37  cases  for  the  relief  of  arti-  \    2  recovered  with  permanent 
ficial  anus  ,         •  =  j  fistulas. 

(  14  died. 
/  24  recovered. 
56   cases  for  gangrene  after  \    3  recovered  with  pennanent 
hernia       .        .        •  ^^= )  fistulae. 

I  29  died. 
8  cases  for  occlusion  of  the  {    2  recovered. 

howel         .         .         .  =  \    6  died. 
10  cases  for  cancer    of    the  \    5  recovered. 

bowel         .        .         .=  I    5  died. 

10   cases   for  injury   to    the  1    6  recovered. 

bowel         .        .        .  i=r  I    4  died. 

*  Gussenbauer,  Aichiv  fiir  Klin.  Chir.,  1878,  page  233.  Baum, 
Centralbl.  fiir  Chir.,  1879.,  page  169. 

fSchede,  Berlin.  Klin.  Woch.,  1878,  page  326.  Martmi, 
Zeitsoli.     f.  Heilkunde,  1880,  page  208  ;  and  others. 

t  Deutsche  Zeitsch.  fiir  Chir.,  1883,  page  230. 


Chap. XXV.]    The  Treatment :  Resection.  489 

The  causes  of  death  in  the  58  instances  are  as 
follows : 


Collapse 

Marasmus  after  fcecal  fistula 
Diseases  not  connected  with  the  original  malady 
Yoniited  matters  entered  trachea  cliuing  opcia 
tion        ....... 

Intestinal  ohstruction  following  the  sutnre  . 

Peritonitis    . 

Causes  not  known         .         •         .         •         • 


6 
1 
3 

1 

3 

34 

9 


The  three  cases  of  fatal  obstruction  inchided  two 
instances  of  contraction  at  the  suture  line,  and  one 
case  of  kinking,  due  to  improper  application  of  the 
suture. 

It  will  be  seen  that  the  chief  cause  of  death  in 
these  operations  is  peritonitis,  and  it  must  be  owned 
that  this  peritonitis  usually  depended  upon  some  flaw 
in  the  details  of  the  operation.  In  some  instances 
fsecal  matter  escaped  into  the  peritoneal  cavity  during 
the  operation.  In  other  cases  the  sutures  were  insuf- 
ficient and  allowed  the  escape  of  contents  after  the 
parietal  wound  had  been  closed.  In  another  set  of 
examples  the  gut  sloughed  at  the  suture  line,  or  union 
did  not  take  place,  or  what  union  had  occurred  broke 
down  after  a  time. 

It  is  not,  tlierefore,  too  much  to  expect  that  the 
mortality  of  the  operation  may  be  very  greatly 
diminished  by  improvement  in  the  details  of  the 
operation. 

2.  In  the  second  method  of  performing  resection  a 
temporary  artificial  anus  is  established. 

The  modus  operandi  in  this  procedure  is  practi- 
cally identical  with  that  first  described,  short  of 
suturing  the  intestine  and  closing  the  abdominal 
wound. 

The  abdomen  having  been  opened,  and  the  diseased 
loop  exposed,  the  clamps  are  applied,  and  the  jjortion 


490  Intestinal  Obstruction.      [Chap. xxv, 

of  intestine  excised  in  the  manner  already  described. 
A  triangular  piece  of  tlie  mesentery  should  also  be 
removed  in  the  operation  when  it  concerns  the  small 
intestine.  The  gap  thus  formed  in  the  membrane 
should  be  closed  by  a  few  points  of  suture.  This 
mode  of  treating  the  mesentery  renders  the  subse- 
quent closure  of  the  artificial  anus  a  much  more  easy 
matter  to  effect.  The  clamp  having  been  removed 
from  the  lower  and  usually  collapsed  end  of  the 
bowel,  the  margins  of  the  divided  intestine  are  care- 
fully secured  to  the  edges  of  the  abdominal  wound. 
Since  the  bowel  above  the  obstruction  is  usually 
greatly  distended,  much  caution  should  be  exercised 
before  the  upper  clamp  is  removed,  lest  any  faecal 
matter  enter  the  peritoneal  cavity.  Before  the 
removal  of  this  clamp  the  abdominal  wound  should  be 
closed  as  far  as  possible.  The  wound  in  the  vicinity 
of  the  upper  segment  of  the  bowel  should  be  well 
plugged,  and  before  the  clamp  is  actually  taken  off, 
this  end  of  intestine  should  be  drawn  well  forward  out 
of  the  wound.  After  the  contents  of  the  bowel  have 
escaped,  the  margins  of  the  intestinal  wound  and  of 
the  parietal  wound  should  be  joined,  as  in  colotomy. 

After  a  while,  the  duration  of  which  must  depend 
upon  the  circumstances  of  each  case,  the  artificial 
anus  thus  formed  is  closed  by  a  further  resection 
operation,  associated  with  suturing  of  the  bowel. 

Of  these  t\vo  methods  of  performing  resection 
there  is  no  doubt  that  the  last  described  is  by  far  the 
better  and  the  safer. 

It  may  be  that  the  operation  of  suturing  the  in- 
testine immediately  after  the  resection  may  be  im- 
l^roved  as  surgery  advances,  but,  as  the  matter  at 
present  stands,  everything  points  in  favour  of  the 
operation  that  demands  the  establishment  of  a  tem- 
porary artificial  anus. 

The  comparative  value   of  these  two  procedures 


Chap.  XXV.]  The  Treatment :  Resection.  491 

has  been  fully  discussed  by  Reicliel  in  the  monograph 
above  alluded  to,  and  tliis  surgeon  has  shown  clearly 
that  the  chief  element  of  success  in  resection  operations 
depends  upon  the  formation  of  a  temporary  fsecal 
fistula. 

It  must  be  borne  in  mind  that  the  patients  who 
are  the  subjects  of  resection  operations  are  suffering 
from  obstruction,  and  often  from  acute  obstruction. 
Their  lives  are  threatened  by  reason  of  this  obstruc- 
tion, and  any  operation  performed  should  give  imme- 
diate and  entii"e  relief  to  the  distended  bowel  above 
the  site  of  the  occlusion.  In  the  second  of  the  two 
methods  above  described  this  relief  is  afforded.  The 
engorged  intestine  can  empty  itself  at  its  leisure.  If, 
however,  the  divided  ends  of  the  bowel  be  at  once 
united  after  the  excision  of  the  diseased  segment,  the 
distension,  to  a  great  extent,  remains,  the  obstruc- 
tion is  but  imperfectly  relieved,  the  gut  at  the  suture 
line  is  paralysed,  peristaltic  movements  must  be  in- 
terrupted at  this  point,  and  free  circulation  of  the 
intestinal  contents  is  thus  rendered  practically  impos- 
sible. The  fact  must  not  be  lost  sight  of,  that  in  re- 
section operations  the  relief  of  an  obstructed  intestine 
is  of  more  immediate  moment  as  regards  the  patient's 
life  than  the  removal  of  an  epithelioma  or  neoplasm 
from  the  walls  of  the  bowel. 

Then,  again,  the  operation  requiring  immediate 
suturing  of  the  intestine  is  long  and  tedious,  and  the 
state  of  the  patient  upon  whom  these  ojoerations  are 
performed  is  usually  such  as  to  render  a  prolonged 
narcosis  most  undesirable  and  most  dangerous.  The 
procedure  that  postpones  the  suturing  of  the  bowel  to 
a  future  period  is  readily  performed,  and,  indeed,  is 
almost  as  simple  as  an  ordinary  enterotomy  or  colo- 
tomy. 

In  all  resection  proceedings  there  is  a  great  risk  of 
death  from  fsecal  extravasation,  and  it  is  needless  to 


492  Intestinal  Obstruction.      [Chap.  xxv. 

point  out  that  this  risk  is  infinitely  reduced  by  a 
perfect  evacuation  of  the  bowel  above  the  obstruc- 
tion. 

In  many  examples  of  resection,  especially  when 
undertaken  for  gangrene,  the  bowel  is  not  in  a  con- 
dition to  ensure  sound  and  perfect  healing.  For  the 
success  of  the  primary  suture  operation  this  ready 
healing  is  essential,  and  it  will  be  obvious  that  in  ex- 
cising the  bowel,  with  this  fact  before  him,  the 
surgeon  would  be  apt  to  remove  too  much. 

Owing  to  the  disturbance  of  the  mesentery  the 
margins  of  the  divided  intestine  are  apt  to  slough  a 
little.  In  the  latter  of  the  two  procedures  now 
under  notice  this  would  prove  a  matter  of  no 
moment ;  in  the  former  it  would  probably  lead  to 
fsecal  extravasation  and  death. 

It  may  be  said,  therefore,  that  in  resecting  the 
intestine  a  temporary  artificial  anus  should  always  be 
established,  and  the  suturing  of  the  bowel  left  to  a 
future  period. 

To  this  rule  one  exception  may  be  made  In 
cases  of  resection  of  small  intestine  high  up  in  the 
jejunum,  the  divided  ends  should  be  at  once  brought 
together  with  sutures  whenever  the  state  of  the  in- 
testine will  permit.  The  mortality  attending  fiscal 
fistulas  in  the  upper  part  of  the  jejunum  is  well  known. 

The  literatiu'e  of  resection  operations. — 
Among  the  more  important  contributions  the  following 
may  be  noted :  Reichel,  loc.  cit.  ;  Bouilly  and  As- 
saky,  Re\^ie  de  Chir.,  1881  and  1883;  Petit.  Bull. 
G^n.  de  Therap.,  Med.  et  Chir.,  Dec.  1882  ;  Koberle, 
loc.  cit,  ;  John  Marshall,  Lancet^  vol.  i.,  1882  ;  Karl 
Jafi'e,  Volkmann's  Sammlung,  1881,  No.  201  ;  Made- 
lung,  Yerh.  d.  d.  Ges.  f.  Chir.,  1881  ;  Czerny,  Berl. 
Klin.  Wochenschr,  1880,  No.  45 ;  Kocher,  Centralb. 
f.  Chir.,  1880,  No.  29  ;  Gussenbauer,  Prager  Zeitschr. 
£.   Heilk,  i.  bd.,   1880;    Bryant,   Med. -Chir.   Trans.,' 


Chap.  XXVI.]         Acute  Obstruction:  493 

1882;  Pv-ydygior,  Berlin.  Klin.  Wochen.,  1881,  Nos. 
41,  42,  43;  ydiede,  Verb,  der  deutsch  Ges.  f.  Chir., 
1879. 


CHAPTER  XXVI. 

THE    SPECIAL    TREATMENT    OP     INDIVIDUAL    FORMS    OF 
OBSTRUCTION.* 

It  only  remains  to  mention  in  the  briefest  possible 
manner  the  particular  treatment  suited  for  each  of  the 
various  forms  of  intestinal  obstruction. 

In  discussing  this  subject  the  classification  that  is 
the  most  convenient  is  that  based  upon  clinical  evi- 
dences, and  that  has  been  adopted  in  the  chapter  upon 
difujnosis.  This  classification  consisted  essentially  in 
dividing  the  various  forms  of  obstruction  into  two 
great  classes,  the  acute  and  the  chronic,  and  then  in 
making  certain  subdivisions  in  each  of  these  two  great 
classes. 

1.    ACUTE    OBSTRUCTION. 

Let  it  be  suj)posed  that  a  given  case  has  been 
diagnosed  to  be  one  of  acute  obstruction.  By  a  further 
step  in  the  diagnosis  let  it  be  supposed  that  it  has  been 
classed  under  one  of  the  four  following  headings  : 

A.  Strangulation  by  bands,  or  through  apertures. 

B.  Volvulus. 

C.  Acute  intussusception. 

D.  Obstruction  by  foreign  bodies,  etc.  (certain  cases). 

A.  Sfraiagrwiatioiii  toy  bands,  or  tlarougli 
apertures,  etc. — Under  this  heading  may  be  in- 
cluded the  following  pathological  conditions  :  (1) 
Strangulation  by  peritoneal  bands ;    (2)   by  omental 

*  This  chapter  must  be  regarded  as  little  more  than  an  index 
to  the  matter  contained  in  the  chapters  on  the  forms  of  ixQ&,%- 
went. 


494  Intestinal  Obstruction.     [Chap.  xxvi. 

cords ;  (3)  by  the  diverticulum  ;  (4)  by  an  adherent 
appendix,  or  Fallopian  tube,  etc. ;  (5)  strangulation 
through  slits  and  apertures.  As  rarer  conditions  it 
would  also  include  (6)  strangulation  over  a  band ;  (7) 
acute  kinking  of  the  small  intestine ;  (8)  some  cases 
of  vohiilus  of  the  small  intestine ;  and  (9)  of  occlu- 
sion by  pressure  of  a  tumour  outside  the  gut. 

In  the  treatment  of  the  case  the  patient  should  in 
the  first  place,  of  course,  be  kept  absolutely  at  rest. 
The  lower  bowel  should  be  emptied  by  an  enema. 
The  patient  should  be  allowed  ice  to  suck,  but  no  food 
should  be  given  by  the  mouth.  The  strength  should 
be  supported,  if  thought  fit,  by  nutrient  enemata, 
although  it  must  be  remembered  that  such  enemata 
may  cause  distress  and  may  have  to  be  discontinued. 
Opium  should  be  given  when  the  pain  is  very  severe, 
and  the  vomiting  marked,  and  especially  in  cases  asso- 
ciated with  collapse.  It  should  be  administered  in 
the  form  of  a  hypodermic  injection  of  morphia.  Great 
care  should  be  used  in  the  giving  of  morphia  in  these 
cases.  It  must  be  remembered  that  while  opium  may 
give  considerable  relief,  it  is  apt,  on  the  other  hand, 
to  mask  the  symptoms,  to  alter  the  clinical  aspect  of 
the  case,  and  to  give  the  surgeon  an  erroneous  notion 
of  its  gravity.  At  the  best  the  drug  can  only  be  re- 
gai'ded  as  a  i^alliative,  and  not  as  a  curative  measure. 
Indeed,  it  should  be  given  in  these  cases  with  the 
same  caution  that  it  is  administered  in  cases  of  stran- 
gulated hernia.  Should  the  patient  become  fully 
narcotised  the  main  symptoms  may  become  so  modified 
that  the  surgeon  may  imagine  the  malady  to  be  under- 
going cure,  while  the  involved  gut  is  becoming  hourly 
more  and  more  hopelessly  disorganised.  It  should  be 
borne  in  mind  that  the  main  use  of  the  drug  in  these 
cases  is  to  combat  collapse. 

With  regard  to  the  curative  treatment  in  the 
present   forms  of   obstruction,   the   only  measure  is 


Chap.  XXVI.]         Acute  Obstruction.  495 

laparotomy.  It  has  been  shown,  that  in  the  first  five 
at  least  of  the  above-mentioned  conditions  spontaneous 
cure,  while  not  absolutely  impossible,  is  yet  so  exceed- 
ingly improbable  that  it  cannot  be  considered  when 
discussing  the  treatment  of  the  case.  In  the  remain- 
ing four  conditions  spontaneous  relief  of  the  obstruc- 
tion is  certainly  not  so  improbable,  but  it  must  be  re- 
membered that  these  conditions  cannot  be  diagnosed 
from  the  rest,  unless  in  the  last-mentioned  form  a  dis- 
tinct tumour  exist,  and  that  even  if  diagnosed  they 
can  be  better  treated  by  laparotomy  than  by  any  other 
known  means.  When  once,  therefore,  the  general 
nature  of  the  case  has  been  diagnosed,  laj)arotomy 
should  be  performed  without  delay.  It  is  worse  than 
useless  to  temporise  with  aimless  enemata,  with  elec- 
tricity, with  massage,  with  applications  of  ice,  and  the 
like.  The  condition  of  the  gut  is  identical  with  the 
condition  in  strangulated  hernia.  In  a  case  of  stran- 
gulated hernia  no  surgeon,  after  the  taxis  had  failed, 
would  think  of  delaying  kelotomy  until  he  had  tried 
galvanism,  enemata  of  tobacco,  metallic  mercury,  and 
other  measures  of  like  character.  Kelotomy  is  in 
itself  an  operation  of  small  magnitude.  It  is  only 
serious  when  delayed,  and  its  success  depends  not  so 
much  upon  the  technical  details  of  the  procedure  as 
upon  the  condition  of  the  gut  at  the  time  of  operation. 
The  present  series  of  cases  are  even  more  urgent  than 
are  any  cases  of  strangulated  rupture,  for  no  taxis  can 
be  applied,  and  relief  can  only  be  expected  from  oper- 
ation. Laparotomy,  therefore,  should  be  performed 
at  once.  It  must  be  remembered  tliat  the  average 
duration  of  life  in  these  cases  is  only  six  days.  Lapar- 
otomy at  present  appears  to  be  a  very  serious  measure, 
but  when  one  comes  to  examine  the  fatal  cases  the 
seriousness  is  soon  explained.  Other  things  being 
equal,  the  success  of  the  measure  depends  little  upon 
the  precise  species  of  obstruction,  and  still  less  upon 


496  Intestinal  Obstruction.     [Chap.  xxvi. 

the  modus  operandi^  the  age  of  the  patient,  and  the 
site  of  the  operation.  It  depends  upon  the  condition 
of  the  gut ;  and,  with  very  few  exceptions,  in  the  cases 
of  death  the  operation  had  been  delayed  until  the  con- 
dition of  the  parts  was  such  as  to  render  any  inter- 
ference hopeless. 

It  has  been  shown  clearly  enough  that  a  simple 
incision  into  the  abdomen  is,  with  certain  precau- 
tions, a  comi:)aratively  trifling  measure ;  but  that  in- 
cision appears  as  one  of  the  very  gravest  and  most 
dangerous  when  in  cases  of  obstruction  its  application 
is  delayed.  If  any  treatment  is  to  be  adopted  at  all, 
let  it  be  adopted  at  once.  I  would  urge  that  lapar- 
otomy should  be  performed  as  soon  as  the  diagnosis  is 
fairly  clear,  and  if  possible  within  the  first  twenty- 
four  hours  after  the  appearance  of  the  symptoms. 
The  operation  is  usually  regarded  as  a  last  resource. 
It  should  be  the  first  resource,  especially  as  it  certainly 
is  the  only  resource.  Moreover,  in  cases  of  doubt,  all 
recent  experience  in  abdominal  surgery  would  speak 
in  favour  of  an  exploratory  incision.  A  simple  cut 
into  the  peritoneal  cavity,  made  with  proper  caution, 
cannot  be  so  calamitous  a  circumstance  as  an  un- 
reduced strangulation,  or  even  as  a  case  of  intestinal 
obstruction  treated  absolutely  in  the  dark. 

I  could  allude  to  several  instances  where  an 
exploratory  laparotomy  has  been  performed,  where 
the  obstruction  has  been  found  to  be  in  the  colon,  and 
where  after  closure  of  the  median  wound  a  lumbar 
colotomy  has  been  performed  with  success. "'*■  In  any 
case,  therefore,  of  acute  obstruction  diagnosed  (surely 
or  even  incorr-ectly)  to  be  of  the  character  with 
which  we  are  now  dealing,  an  early  laparotomy  is, 
I  venture  to  think,  without  doubt  the  most  appro- 
priate, as  it  is  indeed  the  only,  treatment. 

*  See  Lancet,  voL  i.,  1875,  page  369,  case  by  Mr.  Teale;  and 
St.  Thomas's  Hosp.  Reports,  1882,  page  75  ;  case  by  Mr.  Pitts. 


Chap.  XXVI.]         Acute  Obstruction.  497 

Tlie  details  of  the  operation  have  been  ah-eady 
described.  It  only  remains  to  say  a  few  words  as  to 
the  treatment  of  the  obstruction  when  found.  Slender 
"  bands  "  may  be  torn  through  with  the  finger  ;  while 
larger  ones  should  be  secured  by  a  double  ligature, 
and  divided  between  the  two  threads.  It  is  well 
subsequently  to  cut  off  these  bands  close  to  their 
attachments,  as  they  may  give  further  trouble  if  left 
free  in  the  abdomen.  Large  omental  cords  may  be 
clamped,  then  cut,  and  the  individual  vessels  secured 
with  the  finest  catgut.  This  treatment  especially 
applies  to  the  larger  omental  bands,  which  are  oftea 
supplied  with  many  blood-vessels.  Indeed,  such 
"  bands  "  may  consist  of  the  whole  or  one-half  of  the 
omentum  rolled  up  into  a  large  cord. 

In  cases  of  strangulation  by  Meckel's  diverticulum, 
the  process  when  large,  and  especially  when  disposed  to 
become  gangrenous,  had  better  be  excised  near  its 
point  of  origin  from  the  intestine,  and  the  wound 
carefully  closed  by  Lembert's  suture,  or  any  other 
suture  that  will  bring  the  peritoneal  surfaces  in 
contact.  It  is  unwise  to  leave  a  diverticulum  still 
attached  to  the  bowel,  since  it  is  very  likely  to 
become  again  a  source  of  trouble.  The  narrower 
diverticula  may  be  divided  after  having  been  secured 
by  a  ligature.  In  some  cases  the  cut  end  has  been 
clamped  and  fixed  in  the  wound  after  the  manner  of 
treating  the  pedicle  in  a  form  of  ovariotomy. 

If  the  trouble  be  due  to  the  appendix,  the 
adhesions  holding  down  that  process  may  .be  divided, 
or  the  end  of  the  appendix  itself  may  be  cut  off,  and  the 
wound  closed  carefully  with  several  points  of  suture. 

In  cases  of  strangulation  through  slits  and 
apertures,  it  is  well  (whenever  possible)  to  close  the 
abnormal  aperture  with  a  few  points  of  suture  after 
the  gut  has  been  reduced. 

After  an  obstructing  band  has  been  relieved,  care 
G  G — 12 


49^  Intestinal   Obstruction.    [Chap.  xxvi. 

should  be  taken  to  ascertain  that  there  is  no  other 
occluding  cord.  I  might  refer  to  two  instances  where 
there  were  two  bands  causing  obstruction  in  one  case. 
In  each  instance  laparotomy  was  performed,  one  band 
was  divided,  and  in  each  instance  it  was  the  wrong 
band,  or  the  one  causing  the  least  serious  obstruction. 
Both  patients  of  course  died,"^ 

The  amount  of  gut  involved  in  the  forms  of  acute 
occlusion  now  under  notice  is  on  an  average  fifteen 
inches.  It  is  very  commonly  much  less,  and  often  a 
mere  knuckle. 

If  the  strangulated  gut  be  gangrenous,  the 
damaged  pai-t  should  be  resected,  and  the  divided 
ends  of  the  bowel  attached  to  the  edges  of  the 
abdominal  wound.  The  artificial  anus  so  established 
may  be  closed  by  a  subsequent  operation,  as  already 
pointed  out. 

If  a  volvulus  be  found  it  may  be  reduced,  but  if 
irreducible  by  the  usual  means,  the  question  of  re- 
section or  of  enterotomy  must  be  considered. 

Cases  of  obstruction  due  to  the  pressure  of  a 
tumour  must  be  treated  according  to  the  indications 
in  each  es])ecial  case. 

B.  Volvulus. — The  morbid  condition  concerned 
in  this  form  of  obstruction  is  for  the  most  part  that 
known  as  volvulus  of  the  sigmoid  flexure.  To  this 
variety  of  volvulus  the  following  observations  are  in. 
the  main  directed.  Under*  the  same  clinical  heading, 
however,  are  classed  volvulus  of  other  parts  of  the 
colon,  and  occlusion  of  the  colon  by  acute  bending. 

In  the  matter  of  treatment  the  patient  may  be 
brought  early  under  the  influence  of  opium,  and  the 
rectum  may  be  emptied  by  an  enema.  There  is  no 
evidence  to  show  that  a  complete  and  well-defined 
volvulus  of  the  sigmoid  flexure  can  ever  spontaneously 


773. 


*  Lo/ncetf  vol.  i.,  1876,  page  773;  and  ibid.,  vol.  i.,  1873,  page 


Chap.  XXVI.]         Acute  Obstruction.  499 

untwist  itself.  Indeed,  the  longer  the  case  lasts  the 
more  tight  does  the  twist  become.  If  unrelieved,  no 
other  than  a  fatal  issue  is  to  be  anticipated.  Attempts 
at  relief  by  enemata  or  by  rectal  tubes  are  useless,  if 
not  actually  harmful. 

The  treatment  of  these  cases  is  most  unsatisfactory. 
As  the  symptoms  produced  by  the  volvulus  are  acute, 
the  operative  measure  adopted  for  its  relief  has  as  a 
rule  been  laparotomy,  the  cases  having  been  probably 
mistaken  for  acute  strangulation  of  the  lesser  bowel. 
Laparotomy,  however,  is  not  likely  to  prove  other 
than  useless.  The  huge  coil  formed  by  the  distended 
sigmoid  flexure  cannot  be  dealt  with  through  the 
small  incision  permitted  by  an  ordinary  laparotomy. 
If  the  gut  be  punctured  it  may  be  reduced,  but  the 
volvulus  would  probably  reappear  as  soon  as  the 
abdominal  wound  was  closed."^  At  the  same  time 
some  treatment  must  be  promptly  adopted,  since  the 
progress  of  the  case  is  rapid  and  peritonitis  is  apt  to 
develop  very  early.  In  the  first  place,  the  distended 
coil  may  be  tapped  through  the  parietes,  and  failing 
relief  from  that  measure  a  left  lumbar  colotomy 
should  be  at  once  performed.  In  these  cases  the 
colon  is  usually  much  distended  with  fiieces  above  the 
seat  of  the  volvulus,  and  the  lumbar  colotomy  would 
give  very  efficient  relief  if  performed  early  enough. 
If  postponed  for  too  long  a  time  the  distorted  sig- 
moid flexure  may  have  become  gangrenous,  or  peri- 
tonitis may  have  developed  to  a  grave  extent.  Left 
inguinal  colotomy  would  probably  be  impracticable. 
The  incision  would  merely  expose  the  distended  and 
obstructed  coil,  and  would  not  permit  the  surgeon  to 
reach  the  gut  above  the  occlusion. 

In    cases  of    occlusion  of    the   colon  by  kinking, 

*In  one  case  of  laparotomy  that  I  performed  for  volvulus,  I 
could  not  reduce  the  twist  tlirough  the  wound,  nor  could  1  rediice 
it  at  the  autopsy,  until  after  much  distiu-bance  of  the  parts. 


500  Intestinal  Obstruction.     [Chap. xxvi. 

permanent  relief  may  be  given  by  puncturing  the 
colon  and  by  keeping  the  bowel  for  the  future  clear 
by  the  judicious  use  of  aperients  and  by  dieting. 
Should  puncture  fail,  colotomy  would  be  the  best 
method  of  treatment,  provided  that  the  seat  of  the 
obstruction  had  been  diagnosed. 

Volvulus  of  the  right  part  of  the  colon  (a  rare 
condition)  may  be  relieved  very  possibly  by  lapar- 
otomy, and  failing  that  an  enterotomy  should  be  done 
at  the  laparotomy  wound. 

One  surgeon,  who  is  perhaps  a  little  in  advance  of 
the  times,  has  suggested  that  an  irreducible  volvulus 
should  be  removed  by  resection ;  but  at  present  there 
would  appear  to  be  but  slender  bases  for  the  support 
of  this  plan  of  treatment. 

C.  Acute  iiitiissiisception. — The  administra- 
tion of  opium  is  absolutely  essential  in  these  cases. 
By  its  means  peristaltic  movements  are  stilled,  and 
any  increase  in  the  invagination  is  probably  prevented. 
At  the  same  time,  it  must  be  remembered  that  the 
drug  may  mask  the  symptoms  and  may  thus  arouse 
in  the  surgeon's  mind  a  false  impression  as  to  the  im- 
provement effected  in  the  case.  As  has  been  already 
pointed  out,  there  are  substantial  reasons  for  believing 
that  under  the  influence  of  opium,  administered  early, 
an  invagination  may  undergo  cure  by  spontaneous  re- 
duction. I  think,  therefore,  that  in  all  cases,  both  in 
the  young  as  well  as  in  adults,  the  administration 
of  this  drug  should  be  adopted  as  early  in  the  case  as 
l)0ssible.  Presuming,  as  is  very  probable,  that  no 
marked  improvement  follows  upon  its  use,  the  next 
measure  in  the  treatment  consists  in  an  attempt  to 
reduce  the  invagination  by  means  of  enemata  or  by 
insufiiation.  These  modes  of  treatment  have  been 
already  fully  described.  They  have  met  with  very 
ei  couraging  success  in  a  large  and  varied  series  of 
cases,  and  are  worthy  of  a  patient  trial. 


Chap. XXVI.]         Acute  Obstruction.  501 

It  will  be  obvious  that  enemata  or  insufflation  will 
be  quite  useless  when  once  adhesions  have  formed,  or 
when  the  invagination  has  become  for  other  reasons 
irreducible.  Moreover,  should  the  intussusce2:)tum 
have  become  gangrenous  a  forcible  enema  may  cause 
rapid  death  by  separating  the  sloughing  gut  and  per- 
mitting the  intestinal  contents  to  escape  into  the  peri- 
toneal cavity. 

Should  these  measures  fail  or  be  considered  inad- 
missible, there  are  substantial  reasons  for  recommend- 
ing an  immediate  laparotomy,  especially  in  the  young. 
Against  this  operation  many  objections  have  beeii 
urged.  In  the  first  place,  it  is  pointed  out  that  an 
acute  attack  may  become  a  chronic  one,  and  the  patient 
may  live  if  left  alone  for  many  months.  This  may  be  ; 
but  examples  of  the  occurrence  are  comparatively  few, 
since  the  great  majority  of  the  patients  die  long  before 
they  can  enter  upon  the  chronic  disease.  Moreover, 
chronic  intussusception  is  itself  fatal  in  time,  as  has 
already  been  fully  shown.  Indeed,  out  of  fifty-nine  re- 
corded examples  of  chronic  invagination  there  are  no 
less  than  fifty-one  deaths. 

As  a  further  objection,  it  is  said  that  spontaneous 
cure  may  take  place  by  elimination  of  the  gangrenous 
intussusceptum.  But  how  does  this  matter  really 
stand  %  Elimination  of  the  gut  by  gangrene  occurs  in 
about  42  per  cent,  of  all  cases,  but  when  it  has 
occurred  it  by  no  means  follows  that  the  patient  re- 
covers. In  fact,  no  less  than  40  per  cent,  of  the 
subjects  of  spontaneous  elimination  die  of  the  imme- 
diate results  of  the  process  of  separation.  Moreover, 
during  the  first  year  of  life  spontaneous  elimination 
occurs  in  only  2  per  cent,  of  the  cases,  and  between 
the  ages  of  two  and  five  in  only  6  per  cent,  ;  and 
when  it  is  remembered  that  more  than  50  per  cent,  of 
the  total  number  of  examples  of  intussusception  occur 
in  children  under  ten,  it  will  be  seen  that  elimination 


502  Intestinal  Obstruction.     [Chap.  xxvi. 

by  gangrene  offers  no  very  extensive  prospects  of 
sj^ontaneous  relief.  It  is  true  that  the  older  the 
patient  the  more  chance  has  he  of  a  recovery  by  this 
means ;  but  it  unfortunately  happens  that  the  older 
the  patient  the  higher  is  the  mortality  after  the  oc- 
currence of  the  elimination,  so  that  the  chance  of  cure 
becomes  remarkably  slight. 

In  favour  of  laparotomy  in  intussusception  it  must 
be  remembered  that  the  general  mortality  of  the 
disease  is  70  per  cent.,  and  that  80  per  cent,  of 
the  patients  die  before  the  seventh  day.  In  quite 
young  children  the  mortality  is  terribly  high ;  death 
occurs  at  an  early  period,  the  cases  usually  following 
an  acute  course.  In  the  young,  therefore,  laparotomy, 
if  done  at  all,  should  be  performed  within  the  first 
forty-eight  hours,  and,  if  possible,  within  the  first 
twenty-four  hours ;  and  Dr.  Sands'  well-known  case  of 
laparotomy  for  invagination  fully  supports  this  advice."^ 
In  adults  the  question  of  operation  may  be  left  a  more 
open  one,  since  the  chance  of  spontaneous  cure  is  cer- 
tainly increased ;  but  that  chance  is  too  slender  to 
depend  upon,  and  is  more  slender  than  that  incurred 
by  a  laparotomy  performed  in  good  time  and  under 
properly  selected  circumstances. 

In  performing  laparotomy  in  these  cases  the  in- 
vagination should  be  reduced  if  possible,  and,  failing 
this,  the  mass  should  be  resected  by  either  of  the  two 
methods  that  have  been  above  described,  but  preferably 
by  that  that  establishes  a  temporary  artificial  anus. 

D.  Obstruction  by  foreign  bodies,  gall 
stones,  etc, — In  cases  of  subacute  or  acute  obstruc- 
tion due  to  foreign  substances  in  the  intestine  the 
condition  may  in  some  instances  be  met  by  free  doses 
of  opium  followed  in  a  while  by  a  gentle  aperient. 
Li  more  grave  cases  laparotomy  should  be  performed 
and  the  foreign  body  extracted.  The  wound  made  in 
*  Nexo  York  Med.  Journ.,  June,  1877. 


Chap. XXVI,]'      Chronic  Obstruction.  503 

the  intestine  may  be  closed  and  the  gut  returned,  or 
an  artificial  anvis  may  be,  for  a  while,  established. 
The  selection  of  one  or  other  of  these  methods  will 
depend  ob\dously  upon  the  state  of  the  bowel  at  the 
seat  of  the  obstruction.  Its  condition  will  probably 
be  such  as  to  forbid  union  of  the  wound  and  a  return 
of  the  gut  into  the  abdomen. 

2.    CHRONIC    OBSTRUCTION". 

A.  Stenosis  of  the  small  intestiiie. — Under 
this  heading  are  included  a  great  many  pathological 
conditions  which  are  all  marked  by  a  partial  mecha- 
nical occlusion  of  the  lumen  of  the  bowel  associated 
with  the  symptoms  of  chronic  obstruction. 

The  conditions  are  the  following  :  1.  Stricture. 
2.  Bendino-  of  adherent  intestine.      3.   Adhesion  of  a 

o 

coil  in  the  form  of  a  loop.  4.  Matting  of  adjacent 
coils  by  many  adhesions.  5.  Direct  compression  of 
the  gut  by  contracting  adhesions.  6.  Occlusion  from 
shrinking  of  the  mesentery.  7.  Stenosis  from  trac- 
tion. 8.  Some  forms  of  volvulus.  9.  Obstruction 
by  neoplasms.  10.  Some  cases  of  obstruction  by  gall 
stones  and  foreign  substances.  11.  Pressure  of  a 
tumour  outside  the  gut. 

In  all  these  forms  of  obstruction  the  dieting  of  the 
patient  is  a  matter  of  the  very  gTeatest  importance. 
The  food  taken  should  be  moderate  in  amount,  should 
be  composed  of  only  the  most  digestible  substances, 
and  should  be  taken  in  small  quantities  at  a  time. 
By  observing  a  careful  dietary,  and  by  keeping  the 
bowels  clear  by  enemata  and  gentle  laxatives,  the 
patient's  condition  may  be  rendered  endurable  for  a 
considerable  period  of  time.  When  these  means 
cease  to  be  of  use,  and  when  the  malady  becomes 
more  grave  in  consequence  of  repeated  attacks  of  ob- 
struction and  the  mal-nutrition  that  follows  upon 
them,  some  operative  measure  must  be  adopted.     In 


504  Intestinal  Obstruction.     [Chap.  xxvi. 

cases  of  stricture  temporary  relief  may  be  afforded  by 
enterotomy,  but  more  lasting  and  efficient  relief  can 
only  be  obtained  by  resection  of  the  diseased  segment 
of  the  intestine.  In  cases  where  the  stricture  is  epi- 
theliomatous,  where  the  disease  is  still  not  extensive, 
and  where  the  glands  are  not  seriously  involved,  the 
operation  of  excision  is  very  strongly  to  be  advised. 
Enterotomy  or  resection,  and  especially  the  latter,  is 
the  proper  measure  to  adopt  in  cases  of  stenosis  as  a 
result  of  traction,  and  in  cases  of  obstruction  by  neo- 
plasms within  the  gut.  Occlusions  due  to  adhesions 
may  be  relieved  by  laparotomy  and  division  of  the 
adventitious  bands,  and  in  cases  where  the  adhesions 
are  too  extensive  to  be  so  treated  enterotomy  may  be 
performed  to  save  life.  In  any  such  case  the  involved 
coils  may  be  removed  by  resection,  provided  that  too 
extensive  a  removal  of  intestine  be  not  required,  and 
that  the  operation  is  upon  other  grounds  possible  and 
desirable.  In  cases  of  obstruction  by  foreign  sub- 
stances time  should  be  allowed.  In  the  great  majority 
of  instances  the  mass  will  be  evacuated  in  time. 
Slight  aperients  may  be  of  some  use,  and  massage  and 
electricity  have  also  been  credited  with  effecting  a 
cure.  Failing  these  or  other  methods,  the  obstructing 
body  may  Vje  cut  down  upon  and  removed. 

B.  Stenosis  of  the  larg^e  intestine.  —  The 
conditions  in  the  colon  that  as  regards  treatment 
maybe  included  under  this  title  are  :  1.  Stricture;  2. 
Bending  of  the  adherent  colon ;  3.  Compression  by 
adhesions  ;  4.  Volvulus  of  the  caecum  ;  5.  Obstruction 
by  neoplasms ;  6.  Compression  by  a  tumour  outside 
the  gut ;  7.  Some  enteroliths. 

In  all  these  forms  of  obstruction  the  patient's  con- 
dition can  be  rendered  more  comfortable  by  careful 
attention  to  diet  and  by  ensuring  as  complete  an 
evacuation  of  the  bowels  as  possible  by  means  of 
laxatives,  and  especially  by  means  of   enemata.     In 


Chap.  XXVI.]       Chronic  Obstruction.  505 

the  cases  of  obstruction  due  to  pressure  of  a  tumour 
outside  the  gut  some  special  treatment  directed 
against  the  tumour  itself  will  probably  be  indicated. 
When  the  obstruction  is  due  to  an  enterolith  (a  com- 
paratively rare  condition)  relief  may  be  afforded  by 
repeated  copious  enemata,  combined  by  cautiously 
administered  aperients.  Some  surgeons  would  be  dis- 
posed to  rely,  to  some  extent,  upon  electricity  and 
massage  in  these  cases. 

In  the  other  forms  of  obstruction,  as  well  as  in 
those  just  mentioned,  when  a  distinct  diagnosis  is  not 
made,  the  usual  means  of  aff'ording  relief  is  by  colo- 
tomy. 

In  cases  of  stricture  the  site  of  the  colotomy  must 
obviously  depend  upon  the  site  of  the  obstruction,  and 
this  latter  matter  is  by  no  means  easy  to  determine. 
Statistics  dealing  with  the  position  of  strictures  of  the 
colon  show  very  clearly  that  in  any  case  of  doubt  it  is 
better  to  open  the  colon  in  the  right  loin,  or  do  in- 
guinal colotomy  in  the  right  iliac  region.  If,  after 
attempting  right  lumbar  colotomy,  the  ascending 
colon  be  found  empty,  it  has  been  advised  that  an 
enterotomy  should  be  done  through  the  lumbar 
wound.  I  have  already  alluded  to  instances  where 
the  diagnosis  has  been  made  by  means  of  a  median 
laparotomy,  and  where  an  opening  into  the  colon  in 
the  loin  has  been  subsequently  effected  with  success. 
In  several  cases  colotomy  has  failed,  owing  to  the 
presence  of  a  double  obstruction,  one  being  above  the 
artificial  anus.  Thus  in  one  case  the  rectum  was 
found  to  be  partially  occluded,  left  lumbar  colotomy 
was  performed,  but  proved  to  be  useless,  since  an  ob- 
struction existed  also  in  the  small  intestine."^  It 
must  be  observed  also  that  colic  strictures  are  often 
multiple.  Thus,  in  one  case  there  existed  a  stricture 
of  the  rectum,  which  had  been  diagnosed ;  there  also 
*  Path.  Soc.  Trans.,  vol.  iii.,  page  108. 


5o6  Intestinal  Obstruction.      [Chap.  xxvi. 

existed  two  strictures  of  the  transverse  colon  which 
had  not  been  suspected.  Had  left  lumbar  colotomy 
been  performed  in  this  case  it  would  have  proved 
abortive."^ 

The  relative  merits  of  inguinal  and  lumbar  colo- 
tomy have  been  already  discussed. 

In  cases  of  stricture  where  a  more  radical  mode  of 
treatment  is  considered  necessary,  colectomy  may  be 
performed.  This  procedure  seems  to  be  rather 
prominently  indicated  in  cases  of  epitheliomatous 
stricture,  where  by  an  early  performance  of  the 
oj)eration  the  malignant  growth  may  possibly  be 
entirely  eradicated.  The  details  of  the  measure  have 
been  considered. 

In  cases  of  obstruction  by  neoplasms  also  colectomy 
may  be  performed  should  the  general  conditions  of  the 
case  permit  that  procedure. 

C.  FsBcal  acciiiiiulatiou. — In  the  treatment 
of  these  cases  is  involved  the  varied  and  extensive 
methods  adopted  for  the  relief  of  constipation.  Into 
the  consideration  of  these  it  is  unnecessary  to  enter  in 
this  i^lace. 

The  only  question  that  need  be  entertained  is  the 
treatment  of  the  case  when  actual  and  serious  ob- 
struction has  occurred.  In  such  condition  aperients 
are  calculated  to  do  harm  rather  than  good.  The 
main  reliance  should  be  placed  in  copious  and  re- 
peated enemata.  jNIany  continental  surgeons  strongly 
advise  carbonic  acid  enemata  in  these  cases.  Much 
good  has  also  been  effected  by  massage,  by  electricity, 
and  even  by  the  somewhat  questionable  mode  of 
treatment  by  metallic  mercury  in  large  doses.  All 
these  measures  and  their  application  have  been  already 
considered.  In  not  a  few  cases  that  have  resisted  all 
other  treatment  colotomy  has  Ijeen  performed.  I 
think,  however,  that  in  the  majority  of  these  examples 
*  BuU.  de  la  Soe.  Anat.,  1877,  page  519. 


Chap.  XXVI.]       Chronic  Obstruction.  507 

a  correct  diagnosis  was  not  made.  The  cases  wherein 
this  operation  is  actually  demanded  are  very  few,  and 
the  measure  should  not  be  entertained  until  every 
other  mode  of  treatment  has  had  a  patient  and 
repeated  trial.  Lumbar  colotomy  for  faecal  accumu- 
lation must  be  regarded  rather  as  a  surgical  mis- 
fortune than  as  a  recognised  means  of  treatment. 

D.  Chronic  iutuissiisccptioii. — The  great 
fatality  that  attends  this  form  of  obstruction  demands 
that  it  should  be  very  carefully  treated.  Much  relief 
can  in  all  cases  be  afforded  by  a  careful  attention  to 
diet,  and  in  the  most  chronic  examples  benefit  of  a 
temporary  character  has  attended  the  use  of  laxatives. 
In  the  less  chronic  cases,  and  in  those  associated  with 
occasional  and  slight  acute  attacks,  the  nse  of  opium 
is  now  and  then  indicated. 

Attempts  may  be  made  to  reduce  the  invagination 
by  means  of  enemata  and  insuiflation,  since  it  has 
been  shown  that  even  in  intussusceptions  that  have 
existed  for  more  than  a  month,  reduction,  and  fairly 
easy  reduction,  is  not  impossible.  This  measure, 
however,  can  only  be  successful  in  extremely  rare  cases. 
The  only  means  of  relief,  in  the  event  of  failure  of 
non-operative  measures,  is  by  laparotomy,  followed  by 
resection  of  the  diseased  mass  in  cases  where  re- 
duction is  found  to  be  impossible.  This  question  has 
already  been  discussed  in  the  preceding  chapter. 


INDEX. 


Abdomeu,  state  of,  in  intussuscep- 
tion, 229,  241 
, ,    in    strangulation    ■by- 
bands,  76,  88 

, ,  in  stricture,  295,  303 

, ,  in  Yolvnliis  of  sigmoid 

flexure,  147 
AciTte  intussusception,  Diagnosis 
of,  377 

obstruction,  Diagnosis  of,  374 

—— in  cbronic  cases,  388 

in  stricture,  296 

,  Treatment  of,  493 

Adenoma  of  intestine,  309 
Adhesions,  Anonialoiis  forms  of,  96 

• ,  Complicated,  7 

,  Compression  of  the  bowel  by, 

111. 

,  Diffused  peritoneal,  120 

,  Effects  of  traction  upon,  129 

,  Extensive  forms  of,  119 

,  Formation  of,  4 

,  Occlusion  by,  102, 119 

,  Strangulation  througb  slits 

in,  55 
Angioma  of  intestine,  310 
Antiperistalsis  and  Tomiting,  363 
Anuria  and  collapse,  369 

in  intestinal  obstruction,  369 

Aperients  in  intestinal    obstruc- 
tion, 427 
Apertures,  Bare  forms  of,  53 

,  Strangitlation  through,  52 

,  Symptoms  of  strangulation 

through,  62 
Appendices  epiploicae,  Adhesions 
of,  52 

,  Rings  formed  by,  54 

Apj)endix,  Strangulation  by  the, 

50 
Arsenical  poisoning  yersiis  intes- 
tinal obstruction,  414 
Aspiration  of  the  bowel,  Treat- 
ment by,  445 


Auscultation  of  the  colon,  398 
Avenoliths,  338 


Band,  Strangulation  over  a,  97 

Bands,  Anomalous  forms  of  ob- 
struction by,  96 

,  Attachments  of,  20 

,  Complicated,  7,  19 

,  Cousrenital,  37 

,  Double,  17 

,  Methods  of  strangulation  by, 

23 

,  Pathology  of,  13,  14 

,  Strang  ufation  by,  13 

, ,  Amount  of  gut  involved 

in,  59 

, ,  Constipation  in,  81 

, ,  Diagnosis  of,  374 

, ,     Exciting     cause     of, 

70 

, ,  Frequency  of  the  vari- 
ous forms,  56 

, ,  General  constitutional 

symptoms  in,  84 

, ,  Mechanism  of,  59 

, ,  Mode  of  onset  in,  69 

, ,  Pain  in,  71 

, ,  Portion  of  gut  involved 


in,  56 


in,  93 


Prognosis  in,  91 
Spontaneous    recovery 


, ,  State  of  abdomen  in,  76, 

88 

, , of  urine  in,  86 

, ,  Symptoms  of,  62 

, ,  Temperature  in,  85 

, ,  The    previoiis    history 

in,  67 

, ,  Yomiting  in,  78 

,  Tlie  formation  of,  4 

,  Various  forms  of,  15 

,  Y-shaped,  IS 


5IO 


Intestinal  Obstruction. 


Bending  of  adherent  colon,  108, 
123 

small  ixitestine,  109 

of  the  bowel,  Occlusion  by, 

102 

,  Symptoms  of,  108 

Bishop's  clamp  for  resection  ope- 
rations, 482 
Broad  ligament  of  uterus,  Stran- 
gulation by  slit  in,  55 

Csecum.Ulceration  of,  in  stricture, 
280 

,  Volvulus  of,  153,  155,  157 

Calculi  in  the  intestine,  336 
Cancer  of  intestine,  269,  297,  304 

of  mesentery  and  intestinal 

obstruction,  414 
Carbonic  acid  enemata.  Treatment 

by,  444 
Catarrhal  ulcer,  258 
Cholera  vcv&ns  intestinal  obstruc- 
tion, 412 
Chronic  constipation,  344 

obstruction.    Treatment   of, 

503 
Cirrhosis  of  liver  and  intestinal 

obstruction,  414 
Clamps  for  resection  operations, 

481 
Classification    of    intestinal     ob- 
struction, 1 

,  Clinical,  373 

Colectomy,    Treatment    by,    478, 

487 
Colic  intussusception,  170 
Collnpse,  Signification  of,  355 
Colloid  cancer  of  bowel,  269 
Colon,  Adhesions    affecting    the, 
122 

,  ascending,  Volvulus  of,  153 

,  Auscultation  of,  398 

,  Bending    of,    by  adhesions, 

102,  107,  108, 123 

,  Distension  of,  from  traction, 

130 

,  Distortion  of,  123 

,  Stricture  of,  286,  300,  304 

Colotomy,  Inguinal,  471 

,  Lumbar,  471 

,  Mortality  in,  471 

,  Statistics  of,  471 

,  Treatment  by,  470 

Compression  of  the  bowel  by  ad- 
hesions, 111 

by  tumours,  315 

Concretions  in  diverticiala,  43 
of  magnesia  in  bowel,  3;39 


Congenital  forms  of  intestinal  ob- 
struction, 1 
Constipation,  Chronic,  344 

, ,  Causes  of,  347 

, ,  Symptoms  of,  348 

in  intestinal  obstruction,  368 

in  intussusception,  225,  239 

in    strangulation    by    bands, 

81 

in  stricture,  294,  302 

in  volvulus  of  sigmoid  flexure, 

144 

of  unusual  duration,  350 

Cramps  in  acute  strangulation,  87 
Cylindroma,  268,  272 
Czerny-Lembert  suture,  48. 


Diagnosis,  DiflEerential,  371 

,  Errors  in,  400 

of  acute  obstruction,  374 

of    chronic    cases   that    end 

acutely,  388 

of  chronic  obstruction,  3S0 

of  intestinal  obstruction,  355 . 

Diarrhoea  as  a  cause  of  intussus' 
ception,  212 

in  intussusception,  225,  240 

Distension  of  intestine,  Effects  of, 

8 
Distortions  of  the  colon,  123 
Diverticula,  False,  44 

,   ,    communicating    with 

bladder,  49 
Diverticular  cords,  35 

knots,  41 

Diverticulum,  Attachments  of,  33 

in  an  invagination,  215 

,  Knots  formed  by,  41 

,  Strangulation  by,  31,  37 

, ,  Prognosis  in,  91 

, ,  Spontaneous    recovery 

in,  95 

,  The  effects  of  traction  on, 

127,  131 

,  The  true  or  Meckel's,  31 

Double  intussusception,  180 
Duodenum,  obstruction  in.  Diag- 
nosis of,  395 
Dysenteric  ulcer,  255 
Dysentery  and  intestinal  obstruc- 
tion, 415 


Electricity,  Treatment  by,  433 
Enemata  as  means  of  Diagnosis, 
396 

of  carbonic  acid,  414 

,  Treatment  by,  438 


Index. 


5" 


Entevectomy,  Treatment  by,  476, 
460 

Eutcric  intxTSSiisceptiou,  16S 

Enteritis  and  intestinal  obstruc- 
tion, 415 

Enteroceutesis,  Treatment  by,  450 

Enteroliths,  336 

Enterotomy,  Mortality  in,  470 

,  Statistics  of,  470 

,  Treatment  by,  466 

Epithelioma  and  intussusception, 
200 

of  the  intestine,  268,  272 

EiTors  in  diagnosis,  400 

Etiology  of  intestinal  obstruc- 
tion, 3 


Fsecal  accumulation,  Diagnosis  of, 
385 

,  Treatment  of,  506 

masses'.  Obstruction  by,  344 

tumoiu',  352 

Fallopian  tube.  Strangulation  by, 

p  51 

False  diverticula,  44 

Fecnlent  vomiting,  365 

Feeding  of  patients  in  intestinal 
obstruction,  415 

Fibroma  of  intestine,  310 

Fibro-myoma  of  intestine,  310 

Fistula  bimucosa,  115 

Foramen  of  Winslow,  Strangula- 
tion at,  55 

Forcible  eneniata,  440 

Forei.gn  bodies.  Diagnosis  of  ob- 
struction by,  379 

,  etc.,  Treatment  of  ob- 
struction by,  502 

in  the  intestine,  277 

,  Obstruction  by,  319 

Fruit  stones  in  the  intestine,  277 


Gall  stones.  Diagnosis  of  obstruc- 
tion by,  379 

,  Obstruction  by,  323 

,  Position  of,   wben  im 

pacted,  325 

• ,  Prognosis    in    obstruc- 
tion by,  334 

,   Symptoms   of  obstruc- 
tion by,  327 

,  Treatment    of    obstruc- 
tion by,  502 

Gan^-rene  in  intussusception, '196, 
2i7 

in  stricture,  281 

Gussenbauer's  suture,  485 


Hepatic  colic  and  intestinal  ob- 

striiction,  414 
Hernia  and  omental  bands,  30 

as  a  cause  of  str'icture,  263 

as  an  indirect  cause  of  intes- 

tinal.obstruction,  10 

,  Internal,  56 

like  strangulation,  13 


Ice  in  intestinal  obstruction,  432 

Heo-caecal  intussusception,  170 

csecal  valve,  Stricture  of,  262, 

277,  286,  299 

-colic  intussusception,  170 

Ileus  paralyticus,  344 

Impacted  gall-stones,  323 

Ina:esta  as  a  cause  of  intussuscep- 
tion, 213 

Injuries  as  a  cause  of  intussuscep- 
tion, 214 

of  stricture,  265 

Insufflation,  Treatment  by,  442 

Intestinal  calculi,  336 

,  Symptoms    caused    by, 

341 

coUs,  Visible  movements  of, 

370 

concretions,  43 

loops,  Obstruction  by,  113 

stones,  Obstruction  by,  336 

tunioui'S,  309 

Intestine,  small.  Cancer  of,  297 

, ,  Stricture  of,   285,   290, 

291   297 

— 1-,  '-^,  Volvulus  of,  158,  165 

,  The  effects  of   traction  on, 

126 

Intestines,  Matting  together  of, 
113,  119 

Intussusception,    Abdominal   tu- 
mours in,  230,  241 

acute.  Diagnosis  of,  377 

forms  of,  215,  220,  242 

,  Ti'eatment  of,  500 

and  "  spasms,"  203 
Artificial  production  of,  203 
Changes  in  the  gut  above, 


190 


chronic.  Diagnosis  of,  386 

forms  of,  215,  236,  242 

,  Treatment  of,  507 

Clinical  forms  of,  215,  242 
Colic,  170 

Course  and  prognosis  in,  242 
Double  and  triple,  180 
Enteric,  168 
Epithelioma  with,  200 
Etiology  of,  202 


512 


Intestinal  Obstruction. 


Intussusception,  Exciting  causes 
of,  210 

,  Frequency  of,  216,  242 

, ,  in  ileo-ca3cal  region,  209 

, of  various  forms  of,  171 

,  Gangrene  in,  196,  247 

,  General  pathologicarchanges 

ii),  181 

, symptoms  of,  228 

,  Ileo-csecal,  170 

, -colic,  170 

,  Immediate  causes  of,  203 

■ -,  Irreducible,  187 

,  Mode  of  srrowth  of,  172 

, of  onset  in,  218,  236 

,  Mortality  in,  243 

,  Obstruction  and   strangula- 
tion in,  185 

of  the  dying,  173 

,  Pathology  of,  166 

,  Retrograde,  178 

,  Sex  and  age  in,  216,  242 

- — -,  Spontaneous    ciire    in,    244, 
245,246 

,  Subacute  forms  of.  215,  220, 

242 

,  Symptoms  of,  215 

,  The  layers  of,  167 

,  Ultra-acute   forms    or,    215, 

220,  242 

,  Varieties  of,  168 

Intussusceptum,  167  ■i 

,  Changes  in,  195 

,  Elimination  of,  196,  247 

,  Signs  of  separation  of,  251 

Intussuscipiens,  167 

,  Changes  in,  193 

Invaginatio  paralytica,  205 

spasmodica,  203 

Irreducible  intussusception,  187 

Jejuno-ileum,  Volvulus  of,  164 
Jejunum,  Diagnosis  of   obstruc- 
tion in,  395 

Kinkiug,  Strangulation  by,  43,  99 

, ,  Symptoms  of,  102 

Knot   formed    by  the    appendix, 

50 
,  Strangulation  by,  24,  26,  38, 

41 

Laparotomy    during   peritonitis, 

464 

,  Fallacies  in,  458 

for  intussusception.  Statistics 

of,  461 


Laparotomy  for  obstruction.  Sta- 
tistics of,  460 

,  Incision  in,  452 

,  Mode  of  proceeding  in,  455 

,  Mortality  in,  459 

,  Treatment  by,  451 

Lipoma  of  bowel,  310 

Littre's  hernia,  37 

Long  tube  as  a  means  of  diagnosis, 
397 

Loops,  Intestinal  obstruction  by, 
113 

Limd's  inflator,  443 

Lymijho-sarcoma  of  bowel,  314 


Magnesia,  Concretions  of,  339 

Massage,  Treatment  by,  436 

Matting  together  of  intestines, 
113,  119 

Meckel's  divei-ticulum,  Attach- 
ments of,  33 

,  Strangialation  by,  31,  37 

,  Varieties  of,  31 

Meningitis  and  intestinal  obstruc- 
tion, 414 

Mercury,  Metallic,  in  intestinal 
obstruction,  430 

Mesenteric  gland  disease  as  a  cause 
of  intestinal  obstruction,  12 

Mesentery,  Part  played  by,  in  in- 
tussusception, 181 

,    shrinking    of,    Obstruction 

caused  by,  133 

,  Strangulation  by  fixed  por- 
tion of,  51 

, through  slits  in,  52 

Meso-colon,  Part  played  by,  in  in- 
tussusception, 183 

Mucous  casts  passed  per  anum, 
342 

Noose,  Strangulation  by,  24,  38 

Oat  stones,  338 

Obstruction  by  compression,  315 

by  foreign  bodies,  319 

by  gall  stones,  323 

by  intestinal  calculi,  336 

by  neoplasms,  309 

,  Diagnosis  of  site  of,  391 

in  intussusception,  186 

Occlusion  due  to  shrinking  of  me- 
sentery, 1:33 
Oliguria  in  intestinal  obstruction, 

369 
Omental  cords,  Formation  of,  28 
,  Strangulation  by,  28 


Index. 


513 


Omentum,  Straugiilation  tlirongli 
slits  iu,  f  3 

Omplialo-mesenteric  vessels,  Per- 
sistence of,  35 

Operative  treatment  of  obstruc- 
tion, 445 

Opium  in  intestinal  obstruction, 
420 

Ovarian  cyst,  Strangulation  by 
pedicle  of,  52 


Pain,  Character  of,   in  intestinal 

obstruction,  359 
in  complete  and  incomplete 

obstruction,  75 

in     intestinal     obstruction, 

357 

iu  intussusception,  220,  238 

in  strangulation    by    Taauds, 

etc.,  71 

in  stricture,  291,  300 

in  volvulus  of  sigmoid  flexure, 

143 

,  Localisation  of,  in  acute  ob- 
struction, 72 

,  situation  of,  in  intestinal  ob- 
struction, 360 

Paralysis  of  the  bowel,  401 

Peptic  ulcer,  258 

Peritoueal  false  ligaments  (see 
Bands) 

Pej-itonitis  and  l^parotomy,  464 

as  an  indirect  cause  of  ob- 
struction, 3 

deformans,  1:33 

I'ersus  intestinal  obstruction, 

406 

Poisoning  by  arsenic  versus  intes- 
tinal obstruction,  414 

Polypi,  311 

as  a  cause  of  intussusception, 

212 

Pseudo-strangulation,  400 

Puncture  of  the  bowel.  Treatment 
by,  445 


Rectal  tumour  in  intu  ssusception, 

233,  241 
Resection  of  intestine.  Causes  of 

death  after,  489 

,  Clamps  for,  481 

,  Modus  operandi  in  479, 

487,  4S9 

,  Mortality  in,  488 

■  — —,  Sutures  in,  484 

■ ■ ,  Statistics  of,  488 

,  Treatment  by,  476 

H  H 12 


Retrograde  intussusception,  178 
Rigors  in  acute  obstruction,  84 


Sarcoma  of  bowel,  313 
Sigmoid  flexure  and  small  intes- 
tine. Volvulus  of,  151 

,  Volvxilus  of,  131, 151 

, ,  Course  of,  149 

,  Pathology  of. 


1:34 
149 
141 


-,  Prognosis  in, 
-,  Symptoms  of, 


"  Skins  "  passed  per  anum,  342 
Spontaneous    recovery   in    acute 

strangulation,  93 
Stenosis  of  adherent  bowel,  130 
of  the  colon.  Treatment  of, 

504 
Stenosis  of   the  small  intestine, 

Treatment  of,  503 

the  result  of  traction,  126 

Stercoraceous  vomiting,  365 
Stercoral  tumours,  352 
Strangulation  by  a  noose  or  knot, 

24,  38,  41 

by  acute  Mnldng,  99 

by  bands,  Diagnosis  of,  374 

,  Mechanism  of,  59 

,  Pathology  of,  13 

,  Prognosis  of,  91 

,  Symptoms  of,  62 

,  Treatment  of,  493 

by  fixed  mesentery,  51 

by  kinking,  43 

by  Meckel's  diverticulum,  31, 

37 

by  omental  cords,  28 

by  pedicle  of  ovarian  cyst, 

52 
by  the  appendix  vermiformis, 

50 

by  the  effects  of  traction,  43 

• by  the  Fallopian  tube,  51 

in  intussusception,  185 

over  a  band,  43,  97 

through  slits  and  apertures, 

52 

under  a  band,  23 

Strictiu'e  after  hernia,  263 

after  injury,  265 

after  intussusception,  251 

after  ulceration,  254 

,  Cancerous,  267,  297,  304 

,  Cicatricial,  253 

,  General  changes  that  result 

from,  277 


514 


IXTES  TINA  L    ObS  TR  UC  TION. 


Stricture,    its    clinical    beariugs, 

282 
• ,  Modes  of  causing  deatli  in, 

283 
of  ileo-caecal  valve,  262,  277, 

286,  299 

of   the   colon,  Diagnosis  of, 

383 

,  Treatment  of,  504 

of  the  small  intestine.  Dia- 
gnosis of,  380 

■ ,  Treatment  of,  5(»3 

,  Pathology  of,  352 

,  Prognosis  in,  285,  298,  305 

,  sinii^le,  Situation  of,  261 

,  Symptoms  of,  285 

Suspensory     ligament     of     liver, 

Strangulation  through  slit  in, 

55 
Sutures  in  resection   operations, 

4S4 
Swedish  movement  cure,  437 
Symptoms  as  modified  by  the  site 

of  the  obstruction,  391 
Syi^hihtic  ulcer  of  intestine,  258 
Syphon  enemata,  439 


Temperature  in  strangulation  by 

bands,  85 
in      volvulus      of      sigmoid 

flexure,  145 
Tenesmus  in  intussusception,  226, 

240 
Traction  of  the  intestine.  Effects 

of,  126 
,  Strangulation  by  the  effects 

of,  43 
Treatment  by  carbonic  acid  ene- 
mata, 444 

by  colectomy,. 478 

by  colotomy,  470 

by  electricity,  43^3 

by  enemata,  438 

by  enterectoiny,  476 

by  enterocentesis,  450 

by  enterotomy,  466 

by  insufflation,  442 

by  lajmrotomy,  451 

by  massage,  436 

by  non-operative  means,  415 

by  operative  means,  4t5 

by  puncture  of  the  bowel,  445 

by  resection  of  intestine,  476 

of  acute  intussusception,  500 

obstruction,  493 

of    chronic    intussuscei^tion, 

507 
obstruction,  503 


Treatment  of  faecal  accumulation, 
506 

of  intestinal  obstruction,  415 

of    obstruction    by    foreign 

bodies,  etc.,  502 

by  gall  stones,  502 

of  stenosis  of  the  coloii,  501 

of  the    small  intestine, 

503 

of    strangulation    by   bands, 

etc. ,  or  through  apertures,  493 

of  stricture  of  the  colon,  504 

of   the    small  intestine, 

503 

of  volvulus,  498 

,  Special,  of  the  various  forms 

of  obstruction,  493 

Treves'  clamp  for  resection  opera- 
tions, 481 

Triple  intussusception,  180 

Trochar,  Use  of,  in  intestinal  ob- 
struction, 445 

Tubercular  peritonitis  and  intes- 
tinal obstruction,  410 

Tubercular  ulcer  of  intestine,  259 

Tumours,  Compression  of  the 
bowel  by,  315 

formed  of  faecal  masses,  352 

of  intestine,  309 

Typhoid  ulcer  and  stricture,  255 


Ulcer,  Catarrhal,  258 

,  Dysenteric,  255 

,  Peptic,  258 

,  Syphilitic,  258 

,  Tubercular,  259 

,  Typhoid,  255 

Ulcers  of  the  intestine,  254 

Umbilical  fistulae  due  to  the  open- 
ing of  Meckel's  diverticulum, 
31 

Uiine,  Amount  of,  passed  in  ob- 
struction, 369 

,  State  of,  in  acute  strangula- 
tion, 86 

, ,  in  volvulus,  143 


Valve,    ileo-csecal,     Stricture   of, 

262,  277,  286,  299 
Vegetable  concretions,  337 
Volvulus,  Congenital,  163 

,  Diagnosis  of,  376 

,  Forms  of,  134 

of   ascending  colon  and  C8B« 

cum,  153 

of  caecum,  153, 155,  157 

of  jejuno-ileuui,  164 


Index. 


5^5 


Volvulus  of  sigmoid  flexure  and 

small  intestine,  151 

,  Symptoms  of,  141 

,  Causes  of,  135 

,  Course  of,  149 

,  Forms  of,  136,  151 

,  Mechanism  of,  137 

,  Pathology  of,  134 

,  Peritonitis  in,  140 

,  Prognosis  in,  149 

of  small  intestine,   158,  161, 

165 
,  Treatment  of,  498 


Vomiting  and  antiperistalsis,  363 

,  Causes  of,  362 

in  intestinal  obstruction,  362 

in  intussusception,  223,  239 

in  strangulation  hy  bands,  78 

in  stricture,  293,  302 

in  volvulus  of  sigmoid  flexure 

144 

,  Stercoraceous,  365 

,  The  initial,  366 

"Worms  and  intestinal  obstruction, 
343 


CASSELL  &  COMPANY,  LIMITED,  BELLE  SAUYAGE  WORKS,  LONDON,  B.C. 


\\^%^l' 

\ 


'Ce.v/e-S 


^^\i^^il\^\    Q\\s<\-vxoWs\ 


